Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0022, written 16 Jan 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 16 Jan 2019 |
|---|---|
| Reference | 2019-0022 |
| Deceased | George Thompson |
| Coroner | Christopher Morris |
| Coroner area | Manchester South |
| Category | Community health care |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: The Senior Partner, Highlands and Trafalgar Square Surgery, Highlands Surgery, 156 Stockport Road, Ashton-under-Lyne OL7 ONW. CORONER lam Chris Morris, Area Coroner for Manchester South. CORONER’S LEGAL POWERS | make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. http://www .legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www. legislation.gov.uk/uksi/2013/1629/part/7/made INVESTIGATION and INQUEST On 6" September 2018, Christopher Murray, Assistant Coroner for Manchester South, opened an inquest into the death of George Foster Thompson who died on 23" August 2018 at Tameside General Hospital, Ashton-under-Lyne, at the age of 86. The investigation concluded with an inquest which | heard on 8" January 2019. My conclusion was that Mr Thompson died as a consequence of natural causes. CIRCUMASTANCES OF THE DEATH In later life Mr Thompson developed an array of chronic health problems. In addition to being suspected to have dementia, he had diabetes mellitus, heart failure, ischaemic heart disease and high blood pressure. In 2017, he moved into Firbank Lodge Residential Care Home. Over the course of his time there, he developed, and was treated for, a number of chest and urinary tract infections. On 21* August 2018, staff at Firbank Lodge contacted Highlands and Trafalgar Square Surgery requesting a home visit as Mr Thompson had become unwell. The duty doctor who spoke to staff dealt with the call as what he termed in his evidence as a telephone “triage” call, and prescribed antibiotics following a discussion with a carer with a view to adding Mr Thompson to the home visit list the following day if his condition did not improve with medication. The following day, Mr Thompson's condition deteriorated (notwithstanding three doses of oral antibiotics which had been delivered to Firbank lodge) and was admitted to Tameside General Hospital by ambulance where he died on 23"? August. A doctor treating Mr Thompson confirmed the medical cause of his death was: 1) a) Bronchopneumonia; 2) Vascular dementia, ischaemic heart disease, aortic stenosis, chronic kidney disease and Type 2 diabetes mellitus. CORONER'S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. - The evidence before the court was that, on the afternoon of 21° August 2018, there was only one doctor on duty for the practice as a whole. The evidence of the relevant clinician is that in addition to undertaking a (habitually) busy afternoon surgery, he was the only doctor available to dea! with emergencies or clinical queries. In those circumstances and whilst the relevant clinician described his telephone call with the care home in terms of being a “triage” consultation, there was no resource in the practice for a home visit to be undertaken that afternoon even if considered indicated by the doctor. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you and your organisation have the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 13" March 2019. |, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to Mrs Susan Hughes on behalf of Mr Thompson’s family. | have sent a copy of my report to the Care Quality Commission, and Tameside Clinical Commissioning Group, who may find it useful or of interest. . 1am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. Dated: 1g‘ Janyary 2019. ——T€ rea Coroner, Manchester South. Signature: Chris Morris HM
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
H Tpractice highlands & trafalgar square surgery The Highlands Surgery 156 Stockport Road Ashton under Lyne OL7 7NW Tel: 0161 330 2440 Fax: 0161 339 4691 Dr Q Nguyen Dr S. Nabi Dr D. Spreckley Dr A. Goh Dr A. Razak 29/01/2019 HM Area coroner Dear Mr Christopher Mortis, Re: Regulation 28 report ref 11066/CLB. We received your regulation 28 report and concerns. RECEIVED We wish to express our deepest condolences to the family on the passing of the late Mr Thompson. Your concerns from the inquest are that: 1) There was only 1 doctor on duty for the practice as a whole 2) The doctor in question stated he has habitually busy afternoon surgeries and was the only doctor to deal with emergencies and clinical queries 3) There was no resources available to deal with home visits on the afternoon of the 21/8/2018. May I address your concerns in that order. 1) There were in fact 3 doctors working on 21/8/2018. I attached a computer print out of the GPs appointment for that day. In order to secure identifiable data each number represent a patient. Their numbers correspond to their unique computer ID code. 2) Our normal capacity is 16 patients in the morning, 16 patients in the afternoon per GP plus home visits and queries. It is at the individual GP’s discretion how long they wish to 3) see each patient for and they plan their clinic accordingly. Our opening hours are 07:30 till 18:30. The blank space next to a time slot represents an appointment not utilised by a patient, it was either un-booked or the patient failed to tum up. On 21/8/2018 there were 11 appointments unused. 6 of these 11 unused appointments were in the clinic of the doctor in question. 3 of these 6 unused appointments wete in the afternoon. The 5 minutes slots were simple telephone queries. The doctor in question saw 9 patients in the afternoon, face to face consultations. This is well below his usual capacity of 16. Regarding home visits. Most of our home visits are phoned through in the morning before 11am. These are shared out among the doctors on that day. All home visits requested are triaged by a GP to assess if the patient needed a home visit. If we conclude that a home visit is needed we will visit the patient. We have never turned down a visit that we felt needed visiting, it’s not in our culture or clinically safe to do so. On this particular day, there were 3 GPs available to carry out home visits. Our operational capacity for home visit is 4-6 visits for each GP depending on complexity. From memory its extremely rare for us to do 6 visits each, and I haven’t done 6 home visits on one day for 2 years. We normally do between 1-2 home visits per GP per day. On this day the home visits requirement was very low. Only 2 home visits were requested in the morning, both in the same nursing home. One of our GP triaged the visits requested and went to see both patients as she felt the visits were necessary. The doctor in question and one other GP had no home visit to do in the morning. A call from nursing home came through in the afternoon at 14:30. It was given to the doctor in question to deal with as he had no visits in the morning, In answer to your question we have demonstrated that it was not a habitually busy day or afternoon. The doctor in question finished afternoon surgery at 17:20, our surgery closed at 18:30. Attached is our home visit protocol. In devising our home visit protocol, we have taken advice from our LMC (local medical committee). It’s a grey area whether we need to visit patient after we closed at 18:30 and handover to our deputised out of hours service. We have taken the view that if a home visit request came through before we closed then we will visit the patient after 18:30. Our home visit protocol stresses that. We have all in the past, and will continue to do in the future, carry out late visits after 18:30 - the doctor in question had also visited patients after 18:30. On this day we operated so well below our normal operational capacity that there was ample time to visit the patient after afternoon surgery. There are two other layers of resilience that are unique to a group practice of our size. We have two other surgeries nearby that can lend support when our capacity is reached or in emergencies when we have staff sickness. Medlock Vale Medical Practice and King Street Medical Centre. These centres are within 1.5 mile from Highlands and Trafalgar Square practice. Clinicians from these centres can log in our clinical system and notes remotely. This practice of cross cover is well honed and has been executed with success only as recently as last week. We had a group training day on 19™ July 2018. The day was dedicated to our group resilience with home visits and emergencies being the centre point of our training. We stress test our resilience and held a quiz to test our staff knowledge of our operational policies. In answer to the points you have raised, the doctor in question had plenty of time to visit a patient after afternoon surgery. Should he feel that he was unable to so for whatever reason there are two other colleagues he can ask for help in the same surgery and 4 other colleagues he could rely on from our group. Please see attached a copy of the clinic appointment for 21/08/2018 and a copy of our home visit protocol. We have reviewed our protocols in light of your letter and we feel that they are robust for the current team that we have in place. We continually review our working practices to reflect changes in work load, winter pressure, staff changes and sickness/emergencies as well as structural and systems failures. Going forward we will: 1) Arrange telephone triage training for the doctor in question. To be arranged by accredited third party trainers. 2) Arrange one to one training of our systems and processes for this doctor as well as reassuring him of the apparatus in placed to help him perform his duties. 3) Re-communicate our operational manual to all our staff as we had done in the recent group training day of 19" July 2018. 4) Create a formal channel for any member of our team to raise concerns about our operational readiness and work load pressure. T hope you feel that I have answered your concerns, should you require any further information please do not hesitate to contact me. Cert Post Grad GP education. Senior Partner. H.T.Practice Ashton-under-Lyne.
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