Beverley Shaw

HOPWOOD HOUSE MEDICAL PRACTICE

Hopwood House
The Vineyard

Lees Road

Oldham

OL4 1JIN

Tel: 0161 628 3628
Fax: 0161 628 4970
Practice Ref: P85014

25-Jun-2019

FAO Ms J. Kearsley

Her Majesty’s Senior Coroner ave
The Phoenix Centre ' Wwe
L/CPL Stephen Shaw MC Way LF

Heywood

OL10 1LR

Dear Ms Kearsley,

Re: Report to prevent future deaths following the inquest of SHAW, Beverley (Miss)

Further to your Regulation 28: Report letter to prevent future deaths (1) and the inquest for
Miss Beverley Shaw, Hopwood House Medical Practice have reflected on the learnings from
the inquest and looked further into the electronic records of the deceased patient.

I will answer the concerns in the order addressed by the court.
1. Communication

Since the inquest we have as a practice reflected on Beverley’s death and have discussed °
what we could have done differently to prevent her death. We noticed that in her records she
had many failed appointments (DNAs) and possibly not fully engaged with clinicians about
her health. In April 2019 we put together a DNA policy. The policy outlines that patients who
DNA shall be discussed in the practice meeting and a suitable method of contacting the
patient should be sought. On reflection with this patient if we had done this, Miss Shaw could
have been referred onto the Focus Care worker linked to our practice and she would have had
a home visit assessment. From this we may have been made aware of the extent of her Butane
abuse and this could have been communicated to the clinicians and Turning Point.

From the practice team meeting and reviewing her medical records, not much was known
about her butane abuse. As you have highlighted, only one document from the 15" May
20/18 simply recorded “Use of cans of butane daily”. There was no further information given
on this. This was written under the section of illicit drugs and I feel that on reading this
document that it is possible that this statement could have been missed by the GPs when
coding. It may be also to have been overlooked by the practice as the letter was from a
commissioned addiction service, that the Butane addiction was dealt with. However on our
behalf perhaps, we could have prompted for more information regarding this.

On speaking to a drugs worker (that works for Turning Point), attached to our practice,
regarding the recreational use of Butane. He was surprised to hear of the volume that she was
using. He was not aware of assessing any patient who had used Butane to the extent that Miss
Shaw had and he would feed back our concerns to his colleagues.

We also found the electronic code “Misuse of Butane EMISNQMI97”. That we will use in
future to code this on the Problem List.

Regarding our communication with Turning Point, we responded to their letter on the 15"
May 2018 by emailing the information requested. They asked for recent blood tests results,
and a copy of her summary. This included her past medical history and current medication.
A task was sent to reception promptly by the GP, on reading the letter to send the requested
documentation. The audit evidence for this is as attached.

Medication Review

The last medication review was done by one of our regular locum doctors who has been
working at the practice for the last 3 years. From the practice meeting we concluded that the
medication review was sub-adequate and the lead GP of the practice will feed this back to
him. However, given the time limits and pressures in primary care, and the inconsistencies of
CCG employed pharmacists, the practice has made a decision to employ a clinical
pharmacist do complicated medication reviews and help with the workload.
Despite this, as highlighted already by the letter from the 15" May 2018 sent yi
BEE Consultant Psychiatrist), they have a clear accurate record of Miss Shaw's
medication and any drug interactions that may have been overlooked by the practice, perhaps
should have been double checked then.

Looking at the electronic records, and using the Safety check tool, there are, “no high severity
warnings” or contra-indications with the medications. There is a “medium severity warning”,
regarding use of Methadone and Acute Hepatic failure, suggesting avoid or a reduced dose is
used, Again, there was a “medium severity warning” regarding the concurrent use of
Methadone with Olanzapine 5mg Tablets, Amitriptyline, Promazine and Pregabalin causing a
prolonged QT interval. The manufacturers advice was to avoid-use with 2 or more drugs
associated with QT prolongation. Had methadone been added to the medication list, this
perhaps would have been avoided.

This patient was under Pennine MSK persistent pain service Tier 3. Miss Shaw was suffering
from Psychological distress in the context of Trigeminal neuralgia and had a history of
Ekbom’s syndrome.

In the last clinic letter from the pain service dated the 3 August 2018, they had advised to
reduce the Olanzapine to 12.5mg per day in 2 divided doses, then after a month to reduce to
5mg twice daily .which we was promptly changed as per advice.

Duloxetine, Pregabalin, Amitriptyline and Olanzapine were started due to her chronic facial
pain.

Promethazine was started by Raid on the 1 1% September 2017. She had a follow up
appointment with mental health that she did not attend. As Miss Shaw’s engagement with the
community mental health team was compromised this may have had an effect on continuing
the Promethazine. However, I do agree this should have been picked up during medication
reviews and encouragement given to attend her appointments with the community mental
health team. Perhaps a reducing regime agreed with the patient would have been another
suggestion.

Miss Shaw’s medication was listed in the letter from MSK pain clinic. However I note that
Methadone was omitted from the list. I am not sure whether Miss Shaw disclosed her
Methadone intake and perhaps some of the chronic pain medication such as Amitriptyline,
Duloxetine, Pregabalin and Promazine could have been avoided if the pain clinic were aware
of her methadone or Butane use.

I note a mental state exam was done at this clinic and there was no evidence of depressive
cognition.

I note that there were several opportunities where she could have had some of her chronic
pain medication reduced. However these were missed.

Again this will be avoided in future when a clinical pharmacist is employed by the practice
and can go through complicated medication reviews. The GPs in the practice are aware of
this as a significant event and will be mindful of patients on sedatives, chronic pain
medication with methadone and substance abuse.

Records

This is related to the commissioned provider and I hope that they can resolve this issue with
the transfer of full records with a new provider.

We, at Hopwood House Medical Practice are deeply saddened that Miss Shaw’s death could
have been as a result of poor communication and that steps could have been taken early to
prevent this death. Unfortunately we have had to learn humbly from this and will in the future
be: much more vigilant with communication and correspondence, and also medication
reviews, Changes have already been made, to prevent any further similar deaths and will be
ongoing in the future.

Going forward I hope that communications with our drug and alcohol, and other services
improve to ensure that we are made aware of the dangers of Butane. I have also suggested to

the practice that we add Methadone to the patients medication list in all cases to highlight to
clinicians that they are receiving this from the drugs and alcohol team.

The practice would also, if supported through Oldham CCG have a meeting with Turning
Point separately as a learning event to see what further changes we can both make to make
sure miscommunications are avoided in the future

Please express our deep condolences to the family.

Yours sincerely

GP Priniciple
Hopwood House Medial Practice

Email:  

2nd August 2019   

Dear Ms Kearsley 

Re:  Ms Beverley Shaw 

Further to your Regulation 28 report of 10th June 2019 following the inquest into the death of Ms Shaw, we 
can confirm that a full investigation into the matters raised regarding the care received by Ms Shaw has been 
undertaken and we are now in a position to respond to the concerns raised. The matters of concern raised 
and the actions we will take as a CCG to address these concerns are as follows: 

1. 

2. 

3. 

4. 

There was  a  lack  of  communication between  Turning  point  and  the GP  Practice  specifically  in 
respect of Ms Shaw’s use of butane gas. 

There  is  no  record  of  a  response  from  the  GP  practice  to  Turning  point  following  their  letter 
dated the 15th May 2018. 

A  medication  review  took  place  in  the  GP  Practice  in  August  2018…there  is  no  evidence  that 
there was a full review of all medications prescribed to Ms Shaw. 

The Court heard evidence that following the transition from another provider to Turning Point, a 
decision  was  taken  that  all  medical  records  do  not  need  to  be  carried  over  to  Turning 
Point…hence they do not have the full past medical history available. 

The review of the timeline of events with the practice has demonstrated where gaps in communication have 
had  an  impact.  The  practice  acknowledges  the  fact  that  the  reference  to  butane  gas  within  the  illicit  drugs 
section of the letter may have been missed by doctors and Turning Point have also highlighted the need to be 
explicit about substance use in addition to prescribed medications, with both agencies acknowledging that this 
detail could be improved by both parties to ensure recognition of the impact on the individual concerned and 
therefore appropriate treatment and management from a prescribing perspective. 

In respect of the butane gas use, the appropriate electronic code has been identified to flag misuse of butane 
on the EMIS system. This will be communicated to all practices as part of the lessons learned from this review 
to ensure that all Oldham GP practices are aware of this code. 

The CCG is also keen to involve colleagues in our Local Authority Trading Standards department to look into 
the supply of the butane gas in this lady’s local area. As we embrace a place based method of working it is 
vitally important that we are looking at all influencing factors and the potential sale of large quantities of gas 
needs further scrutiny. 

	
 
 
 
 
            
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 The  events  surrounding  Ms  Shaw’s  death  highlight  the  requirement  for  effective  and  up  to  date  ‘Did  Not 
Attend’ policies to be followed in Primary Care and to initiate discussion in practice meetings to ensure holistic 
information  is  shared  and  reviewed  by  the  team  in  a  manner  which  supports  clinicians  to  make  decisions 
based on the full facts and influencing factors. Such discussions can trigger communication back to secondary 
providers such as Turning Point to clarify and/or share information. The presence of Focussed Care within a 
number  of  Oldham  practices  has  been  seen  to  support  such  instances  where  substance  use  influences 
existing  co-morbidities  and  as  a  CCG  we  are  promoting  wider  uptake  of  this  across  the  Oldham  footprint. 
Practices that do not have a focussed Care worker directly linked to their practice do have access through the 
central office and this will be re-communicated as part of the lessons learned from this situation. 

From  a  system  perspective,  there  is  clear  learning  in  reviewing  the  medication  and  prescribing  issues 
identified in Ms Shaw’s situation. This has highlighted some locum GP competency issues within the practice 
that have been addressed through the appropriate channels. The learning that has arisen from reviewing this 
lady’s care as a significant event has emphasised the importance of careful consideration of methadone use 
and subsequent or potential prescribed medication interactions. There is the facility for medications prescribed 
external to the practice (i.e. hospital or externally commissioned service such as Turning Point) to be entered 
into the EMIS system and therefore prompt alerts. This will also be highlighted to all practices and supported 
through the clinical pharmacy in-reach into all clusters. 

Oldham CCG has a number of Clinical Pharmacists who work at Cluster level to support practices, carry out 
audit  work  and  deliver  CCG  commissioned  pieces  of  work.  It  is  not  within  the  current  resource  for  these 
individuals to carry out reconciliations for every patient within every practice, therefore the role of the Clinical 
Pharmacist  would  not  necessarily  have  picked  this  issue  up.  The  CCG  believes  that  the  focus  on  entering 
externally  prescribed  medications  onto  the  system  as  described  in  the  paragraph  above  is  a  safer  way  of 
improving alerts & visibility of such interactions. 

The CCG are co-ordinating a learning event with Hopwood House Medical Centre and the Oldham Turning 
Point team to facilitate a group reflection and agreed actions on how we can improve working relationships. 
The learning from this will also form the basis of a learning event that Turning Point are undertaking across 
the borough with those GP practices signed up to shared care arrangements. 

We hope that this demonstrates that the CCG has robustly reviewed all aspects of the concerns raised within 
the  Regulation  28  notice  and  provides  assurances  regarding  the  lessons  learned  and  the  actions  taken  to 
prevent reoccurrence in the future. 

Please do not hesitate to contact either one of us should you wish to discuss and further concern. 

Kind Regards 

ith

Turning Point
3rd Floor
Standon House
21 Mansell Street
London E1 8AA
Ms Joanne Kearsley
Senior Coroner
H M Coroner’s Office
The Phoenix Centre
L Cpl Stephen Shaw MC Way
Heywood
OL10 1LR
31st July, 2019
Dear Ms Kearsley,
We were disappointed to receive the regulation 28 report from you dated 10th June, 2019.
At Turning Point we pride ourselves on providing safe and well governed services and our key
regulator, the Care Quality Commission, has rated us as Good or Outstanding in all our community
substance misuse services. The foundation of this high quality and governance is based on a learning
culture and continual improvement.
Whilst we recognise that the clinician had written to the GP, we accept that there is more that we
could do to improve this communication, not only in this tragic case but also more broadly across
our substance misuse services. Therefore, we have undertaken a wide ranging review of GP
communication across all our community substance misuse services, not just in Rochdale and
Oldham. That review has been led by our Senior Management Team, including our senior clinical
team, and our Risk and Assurance department.
This review has highlighted the key processes that we needed to change in order to improve
effective communication and reduce the risk of future recurrence. Those processes are the template
used by prescribers to review clients, the frequency of communication with GPs, the way that
communication is recorded on our electronic client records system and the processes for audit of
the frequency of that communication.
We also reviewed our systems for following up requests to GPs for information and the way in which
we transfer client data at the beginning and at the end of contracts.
The results of those reviews are captured in the attached action plan.
I am pleased to say that we have made all those improvements not only in Rochdale and Oldham but
also in all our community substance misuse services across the country and made the changes within
our planned timescales. We have also agreed how we will monitor compliance with those new
standards as part of our routine management audits.
We believe that these changes will ensure that we are able to prevent recurrences of the issues you
have raised with us in your regulation 28 report.
We are aware that a copy of this response may be sent to the family of Ms Shaw and on behalf of
the staff team and the organisation I wish to offer our sincere condolences to them for the sad loss
of their loved one.
Should you wish me to clarify any of the action plan or the points above, please do not hesitate to
contact me.
Yours sincerely,
Director of Public Health and Substance Misuse