Gwilym Price

Cannock Chase Clinical Commissioning Group 
East Staffordshire Clinical Commissioning Group 
North Staffordshire Clinical Commissioning Group 
South East Staffordshire and Seisdon Peninsula Clinical Commissioning Group 
Stafford and Surrounds Clinical Commissioning Group 
Stoke-on-Trent Clinical Commissioning Group 

Staffordshire and Stoke-on-Trent CCGs’ Headquarters 
First Floor 
Staffordshire Place 2 
Stafford 
ST16 2LP 

Our Ref: HJ/LM/akb 

Your Ref: AAH/EAS 2812588 

11th September 2020 

Private and Confidential: 

Andrew A Haigh 
Senior Coroner, Staffordshire South 
Coroner’s Office 
No 1 Staffordshire Place 
Stafford 
ST16 2LP 

Email: sscor@staffordshire.gov.uk 

Dear Mr Haigh 

Re: Gwillym Emrys PRICE 

Thank  you  for  your  letter  of  the  13th  July  2020  providing  a copy  of  your  Regulation  28  report.  
Accordingly, please find below the response to this report as requested: 

Practice response 
  Mr Price was seen at the practice by a GP on the 19th February 2020.  At 16:18 the GP had 
a long chat to the patient and the patient was provided with the Crisis team number if needed.  
The patient agreed to be referred to the Mental Health team as an amber case to be seen 
within 3 days.  The patient was happy with the plan and advised that we would review him as 
required.  

  A referral to the Mental Health Team, Midlands Partnership Foundation Trust was completed 
on the 19th February 2020 by the GP stating that assessment was needed within 3 days.   
  The  medical  secretary  at  the  practice  contacted  Midlands  Partnership  Foundation  Trust’s 
Mental Health Team on the 20th February 2020 by telephone to confirm that the referral had 
been received, confirmation of receipt was confirmed and the team advised that the patient 
would be triaged on the same day.   

  The practice received notification from the Mental Health Team by copy of letter to patient 
showing that a telephone conversation / assessment had taken place with Mr Price on the 
20th February and that a face to face assessment appointment had been organised for the 
13th March 2020 

  The practice had no further contact with the patient prior to his death.   

Update from Data Quality Specialist (DQS)  
  The practice clinical system has been checked as well as the patient’s referrals prior to death 
–  the  Midlands  Partnership  Foundation  Trust  form  used  was:  RF580  CMHT  MH  Referral 
Stafford 200418. The referral made on the 19th February 2020 from Gnosall Surgery at that 
time was the latest referral form on their clinical system. 

  The Midlands Partnership Foundation Trust referral form has not been updated since 2018, 

but it is the latest version made available.  

  Data Quality Specialist team confirmed that they had not received an updated version of the 
Midlands Partnership Foundation Trust referral form to upload onto the clinical systems. If the 
referral form had been emailed out to practices directly some practices might have converted 
the form themselves onto the system.  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   -  Service  Manager  (Mental  Health)  at  Midlands  Partnership 

Update  from 
Foundation Trust 
  The single point of access team confirmed that the patient’s referral had been received. The 
referral form received from Gnosall Surgery was on the old referral form however the single 
point  of  access  still  processed  the  referral  form  and  informed  the  practice  that  the  wrong 
referral form had been used.  

  The referral was not rejected on the basis it was on the incorrect referral form.  
  Midlands  Partnership  Foundation  Trust  confirmed  that  some  GP  practices  are  using  the 

correct referral form while others continue to use the old version.  

  The new referral form was shared with GP practices via email from the single point of access 

team.  

Conclusion  
  The GP practice referred the patient and ensured the referral was received and actioned by 

Midlands Partnership Foundation Trust in a timely manner.  

  The GP practice was not aware that the wrong referral form had been used. 
  Midlands Partnership Foundation Trust had emailed the new version of the referral form out 

to practices. They were not aware of a process for updating referral forms. 

Action 
1.  Clinical  Commissioning  Group 
(CCG)  to  link  Midlands  Partnership 
Foundation  Team  and  the  DQS 
Team to ensure the most up to date 
referral  form  is  uploaded  onto  the 
practice clinical systems. 

2.  Midlands  Partnership  Foundation 
Trust to provide the updated referral 
form to the DQS Team. 

3.  DQS  Team  to  upload  the  correct 
Midlands  Partnership  Foundation 
Trust  referral  form  onto  all  GP 
Practice clinical systems and ensure 
any previous versions are removed. 

4.  DQS to confirm to the CCGs that the 
correct referral form is now available 
to all GP Practices and that the old 
referral form has been removed. 

5. 

6. 

The CCGs Quality Team to discuss 
information  sharing  processes  with 
Midlands  Partnership  Foundation 
Trust and ask if they had put an entry 
of  the  incorrect  referral  form  onto 
their DATIX system. 

The  CCGs  Primary  Care  Team  to 
send  communications  out  to  all  GP 
Practices  highlighting  the  need  for 
practices to report any notification of 
incorrect  referral  forms  through  the 
CCGs DATIX process. 

Responsible 

Due Date 
28/08/2020 

Action Complete 
Complete 

03/09/2020 

Complete 

09/09/2020 

09/09/2020 

09/09/2020 

09/09/2020 

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 Action 
7.  CCGs and DQS Team to produce a 
Standard  Operating  Procedure 
(SOP) 
for  removing  old  referral 
forms  and  managing  updated 
versions. This will be emailed out to 
all GP Practices.  

8. 

The  CCGs  to  develop  a  robust 
process  within  Primary  Care, 
Commissioning and the DQS Team 
to  ensure 
forms  are 
referral 
managed,  updated  appropriately 
and  approved  through  governance 
processes. 

10.  The Primary Care Team to produce 
a  SOP  for  dealing  with  Coroner 
Regulation28 responses. 

Responsible 

Due Date 
09/09/2020 

Action Complete 

30/09/2020 

16/09/2020 

Should you have any further queries regarding this report please do not hesitate to contact us. 

Yours sincerely 

Executive Director of Primary Care and Medicines Optimisation 

(Signed in absence of 

, Executive Director of Nursing and Quality) 

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