Sam Pringle

4th Floor 
Stopford House 
Piccadilly 
Stockport 
SK1 3XE 

Tel: 0161 426 9900 
www.stockportccg.nhs.uk 

Your ref:  311497 
Our ref:   STOCCG00878/cm 

22 June 2020 

Mr Jason Wells  
H M Assistant Coroner 
(South Manchester) 
H M Coroner’s Office 
1 Mount Tabor Street 
Stockport 
SK1 3AG 

Dear Mr Wells 

Regulation 28 Report to Prevent Future Deaths  
Sam Robson PRINGLE (Inquest date 6 December 2019)  

We refer to your report dated 28 April 2020 in relation to the above case; we are sorry to learn of the 
circumstances surrounding the death of Mr Pringle, and would offer our collective condolences to his 
family. 

Stockport  CCG  has  worked  together  with  Pennine  Care  NHS  Foundation  Trust  (PCFT)  and  the 
Greater  Manchester  Medicines  Management  Group  (GMMMG)  in  the  review  of  this  case  and  we 
respond jointly to you which we trust is acceptable.  

The  senior  leadership  across  all  3  organisations  have  met  to  review  this  case  and  to  consider  the 
steps  we  can  take  across  the  system  to  reduce  the  likelihood  of  any  other  patients  experiencing 
delays  in the  prescribing  of Lithium  and  /  or  other medications governed by  a Shared  Care  Protocol 
(SCP).    

It should be said that shared care has been  an ongoing and challenging GM work stream, as it was 
previously a known area of risk at the transfer of care. To that end GMMMG has a library of 58 current 
SCPs  and  an  archive  of  almost  80  previous  versions.  The  procedures  in  place  to  date  have 
undoubtedly made transfers of care safer for countless patients, so when it does not go as planned we 
review and make improvements. 

From  2018  GMMMG  will  only  approve  an  SCP  where  assurance  that  robust  commissioning  and 
provisions arrangements are in place. This lithium SCP was approved prior to that procedure being in 
place.  
The outputs from the multi organisation meeting on 1st June 2020 were taken to GMMMG on 11th June 
for consideration. The group reviewed an anonymous version of this unfortunate case and discussed 
wider lessons which can be learnt to prevent a similar occurrence.  

   
 
 
 
 
 
 
 
 
 
 
 
  
 It  was  concluded  that  there  are  specific  learnings  from  the  individual  circumstances  which  the 
individuals  and  organisations  involved  have  learned  from.  Given  the  wider  system  of  shared  care 
within  which  this  occurred,  lessons  for  the  Greater  Manchester  health  and  social  care  system  were 
discussed which it will learn from.  

We shall detail these separately below: 

Specifics of the case 

It is apparent that in this case there was a communication breakdown between the psychiatrist and the 
GP,  with  the  former  expecting  the  patient  to  communicate  the  final  decision  around  choice  of 
treatment  (lithium)  to  the  GP. While  it  is  recognised  that  lithium  is  a  well-established  treatment,  with 
which  many  GPs  will  have  experience,  communication  via the  patient  is  not  reliable  nor  acceptable. 
The  consultant  had  informed  the  GP  of  the  two  options  given  to  the  patient  and  provided  written 
advice  to  the  GP  around  initiation  in  the  discharge  letter  for  both  medicines  based  on  the  patients 
chosen treatment. This was to support the GP in prescribing the medicine of choice. 

The  procedure  for  sharing  care  across  Greater  Manchester  has  been  in  place  for  some  time  and 
clearly expects a specialist to make an initiation decision and request in writing that the GP takes on 
continuation  of  supply,  which  the  GP  must  confirm  is  acceptable.  Generic  template  letters  and  all 
shared  care  protocols  approved  by  GMMMG  to  facilitate  this  process  are  available  on  the  GMMMG 
website. This unfortunately did not occur this in this case as you highlighted. 

Stockport CCG have a quality scheme in place, which facilitates shared care and Dr Woodworth has 
communicated  to  colleagues  in  General  Practice  to  highlight  this  issue  and  ensure  that  any  similar 
problems with a shared care process are highlighted to the CCG, such that there is oversight and an 
opportunity to ensure patients get their treatment safely and in a timely manner. 

Pennine Care senior managers and clinicians have discussed the case with colleagues at the Drugs 
and  Therapeutic  Committee  and  reasserted  the  importance  of  communication  for  safe  transfers  of 
care.  

These actions have already occurred. 

Greater Manchester system learnings  

These reviews highlighted that although there are SCPs and a process in place, in some cases there 
is  referral  within  the  published  protocols  to  ‘local  commissioning  arrangements’  which  may  allow  for 
unwarranted variation which appears to have contributed to a lack of clarity and delay in this case. this 
is  the  case  with  the  lithium  shared  care  guideline  which  identifies  that  where  local  commissioning 
arrangements allow the GP can be asked to initiate the lithium by the specialist. This is the case for 
GP practices usually covered by this consultant.  

The  issues  highlighted  have  led  to  a  wider  review  of  all  GM  processes,  inform  the  culture  of 
continuous quality improvement and it is expected that learnings will have a positive impact for similar 
clinical situations across all of Greater Manchester.  

As a result of this case it was agreed that: 

  A full review of the content of all Shared Care Protocols is required so as to ensure 

consistency, improve safety and prevent any delay for patients accessing their medications 
as occurred in Mr Pringle’s case.   

o  Agree a risk based prioritisation of SCP review 
o  Agree timescale for review with GMMMG and GM Directors of Commissioning 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
   Make recommendations for a unified GM position on implementation of SCPs.  

o  This will ideally be a de minimus, standardised GM process.  
o  Where a GM standard is not adopted due to local commissioning considerations, clinicians 

must have access to an agreed local process, which is clearly documented and 
communicated.   

o  GMMMG to assure implementation of standards.  

  Take account of necessary changes in practice as a result of Covid 19   

Impact on secondary care repeat prescribing systems.  

o 
o  Electronic shared patient records to ensure/ assist clear communication  
o  Where best practice is identified it will inform GM standards 
o  Engage with external stakeholders such as the Care Quality Commission (CQC) who 

inspect care establishments to encompass their shared care learnings in providers and 
GPs into this review. 

  Develop  business  cases  for  GM  approval  where  additional  funding  and  assurance  is 

required, 

o  Consider  approving  of  SCPs  and  related  pathways  as  policy  only  when  funding  and 

assurance in place. 

o  Consider reconciliation of local approval of GM standards to assure consistency for all GM 

residents. 

o  Assurance required if local process deviates from the agreed position.  

  Ensure  all  independent  sector  providers  comply  with  the  same  GM  standards  as  NHS 

providers  

As you can see from the number of proposed actions this is a significant system wide piece of work. 
These actions will be prioritised by the Pathways and Guidelines Development subgroup of GMMMG 
at its July meeting and the subgroup’s plan approved by the August GMMMG.  

It  is  anticipated  that  it  will  take  several  months  to  fully  review  all  SCPs  and  implement  the  systems 
proposed, further complicated by the Covid-19 recovery. We intend to continue this work as quickly as 
possible. 

We hope the above is acceptable to you but if you have any questions in the meantime please do not 
@nhs.net  or 
hesitate  to  contact  us  via  e  mail  at 

@nhs.net  , 

@nhs.net  

Yours sincerely 

Dr Simon Woodworth 
Medical Director                                         Medical Director  
Pennine Care FT 
Stockport CCG  

Dr Henry Ticehurst  

Dr 

            Chair and GP 

GMMMG