George Townsend

.. 

t.!1lki 
Trafford 
Clinical Commissioning Group 

Private  & Confidential 

F.A.O: Alison Mutch 
HM Senior Coroner 
Coroner's Court 
1 Mount Tabor Street 
Stockport 
SK13AG 

1st Floor 
Trafford Town Hall 
Talbot Road 
Stretford 
Manchester M32 0TH 

28th July 2020 

Dear Ms. Mutch1 

Re:  Mr George Tow~send, Case Number 313628 

I write in response to your letter dated 4th June 2020, and respond accordingly to the 
matters raised  in the corresponding Regulation  28 Report in  relation  to the  death  of 
the late  Mr George Townsend.  Firstly,  on  behalf of Trafford Clinical  Commissioning 
Group  (CCG),  I  would  like  to  offer  Mrs  Townsend  and  her  family  our  sincerest 
condolences and we hope this  response helps to answer any questions that remain 
outstanding for her. 

Gloucester House  Medical  Centre  has  been  under the  caretaking  arrangements  of 
Firsway Health Centre in Sale, Trafford since 151  October 2019. This arrangement was 
due to the mutual termination of the contract between D r - (M r Townsend's GP 
prior  to  his  drath  in  August 2019)  and  Trafford  CCG,  thereforef  in  compiling  this 
IGP  Partner fr9m  Firsway Health 
response we rave liaised with Dr 
Centre to gain access to the patient records and establish what has been put in place 
following the inquest to avoid any future reoccurrences of this nature with this practice. 
We have also considered any wider learning and support across the borough as part 
of this response. 

You specifically asked us as a CCG to respond to section 5:  Matters of Concern, and 
we would like to offer the following information and context. 

1. 

The Inquest heard that Mr Townsend should have been seen by a GP and 
had  further tests  prior  to  his  admission  to  Salford  Royal  Hospital.  The 
inquest heard  that at the  GP  practice in  question there were  insufficient 
GP's  to  see  patients.  In  addition  there  was  no  evidence  of  a  clear 
escalation process from the Nurse to a Doctor within the Practice 

To help us to respond to these practice specific issues we have taken the opportunity 
to review the MrTownsend's patient records as well as the GP rota for the period when 

1 

 ,.,,:,1 

Trafford  , 

Clinical Commissioning Group 

the Advanced Nurse Practitioner (ANP) was involved in the management of his Gastro 
Oesophageal Reflux Disease which was from 241h  June 2019. 

The table below shows the number of occasions he was assessed from 24th June 2019 
up to 20th August 2019 and the GP availability at the practice at the time. 

Date 

Assessment 

GP  availability 
number fof GP's) 

in  Practice  Y/N  and 

24/06/19 

03/07/19 

19/07/19 

01/08/19 

16/08/19 

20/08/19 

Telephone  consultation  with  Yes-all day (1) 
ANP 
Telephone  consultation  with  No 
ANP 
Telephone  consultation  with  Yes (2) AM and (1) PM 
ANP 
Telephone consultation with 
ANP 
Telephone consultation with 
ANP 
Home visit undertaken by 
ANP 

Yes All Day (1) 

Yes AM (1) 

Yes All Day (2 - 1 am only)

-
··-

Whilst there are general guiding principles and different methodologies for calculating 
the number of GPs to cover the  number of patients a  practice has,  GP cover varies 
from  practice  to  practice.  The  earlier diagnostic  work found  that  the  practice  had 
slightly more GP appointments available to patients than average. 

Just prior to the 1st  of August 2019 (251h  Ju y 2019) the Practice Manager contacted 
the CCG to explain that the practice had clinical cover in place, but unfortunately after 
arranging  Locum GP's they had failed to commence their agreed sessions. On these 
occasions the practice ensured that there was GP cover provided by the Out of Hours 
provider,  Mastercall.  This  meant  that  whilst  the  ANP  was  the  only  clinician  in  the 
practice on  some occasions, there was a GP available by phone for clinical advice. 

The  information  in  the  table  above  specifically  identifies  3rd  of July  2019  and  the 
afternoon  of 1st August 2019 as  two dates where the ANP assessed  the patient but 
there was no GP physically in practice at those times, with this said, should she have 
needed  to  escalate any  clinical  concerns  this  could  have  been  done by contacting 
Mastercall over the phone. 

We are also aware that there were no GP's in practice on  13th and 14th  August 2019 
where the same support as above would have been available if required. 

2 

 t.!1:ki 
Trafford 
Clinical Commissioning Group 

To offer further assurance around  GP availability generally, the  CCG has a Primary 
Care  Workforce  Delivery  Group which  has  a  remit  to  review  current  primary  care 
workforce supply and demand in Trafford, and to make recommendations for 
improvement and sustainability, aligned to integrated commissioning principles. Some 
of its key actions include; 

•  To gather data on current local primary care workforce populations 
•  To identify areas that have the greatest need for a workforce model 

An example of an area of work undertaken by this group includes leading on the GM 
GP Retention Scheme which aims to facilitate initiatives to enable clinicians to stay in 
the workforce, through promoting new ways of working and providing a more flexible 
offer that will create·a sustainable model within general practice. The CCG is keen to 
attract,  train  and  retain  clinical  roles  and  so  part  of Trafford's  allocated  funding  for 
2020/21  has  been· used  to  secure  placements  on  the  Basic  Trainer  Course  for  5 
Trafford GPs, increasing the number of training environments within the borough. This 
initiative  not only  provides  placements  for training  clinicians  but  also  supports  the 
professional development of our existing workforce. 

2. 

The particular risks he presented with, his background health issues were 
not recognised when he showed signs of being unwell. 

To help the CCG to respond to this element, D 
for Clinical Quality, Trafford CCG,  has liaised with Dr 
GP Partner at 
Firsway Health  Centre the practice who  are currently care taking  Gloucester House 
Medical Centre. 

Dr-
has also  undertaken  a  review of ~r Townsend's  medical  records  for the 
time period in question and we have been provided with some supporting information 
from  Firsway (Appendix One), to help us understand further what learning has taken 
place to prevent any future deaths of this nature from this practice. 

Within  the  supporting  information,  the  practice  describes  some  of  the  systemic 
changes that were needed in light of the historical cultural issues within the practice. 
They have listed a number of key patient safety actions that have taken  place since 
they took over Gloucester House Medical Practice, and this includes the following:-

•  Robust clinical staffing arrangements with a mix of salaried and partner GP's 
•  Fortnightly clinical briefing sessions (daily since COVID-19) 
•  Robust process in  place for any member of the nurse team to escalate issues 

to a GP if needed. 

•  New nurse working practices and  protocols  in place directed by Firsway's GP 

Nurse Lead/Partner 

•  Ongoing work to review and implement new practice policies and procedures 

3 

 ,~,:~1

Trafford 
Clinical Commissioning Group 

To offer  some  wider  assurance  around  escalation  and  nursing  support,  the  CCG 
confirms that all Practice Nurses in Trafford are given the opportunity to gain  clinical 
supervision  which  is  a  formal  systematic  and  continuous  process  of  professional 
support and learning for practicing nurses. This is provided by the CCG Practice Nurse 
Development Lead, who is also a qualified practice nurse herself. This is a self-referral 
process  which  relies  on  the  Practice  Nurses  contacting  the  Practice  Nurse 
Development Lead  directly and  arranging  a clinical  supervision  appointment.  In the 
case of an Advanced Nurse Practitioner the expectation is that they would seek clinical 
supervision from any of the GP's in their practices. 

3. 

The quality of the written medical notes at the GP practice was poor. 

medical records over the period 
Dr Prasad has undertaken a review of Mr 
in question and concludes that, although the note keeping could be better, there was 
sufficient documentation within the patient consultations to form a view. 

As well  as this  review,  Dr-
from  Firsway 
who  we  understand  was  present  at  Mr  Townsend's  inquest  and  discussed 
documentation at the practice and the quality of the written medical notes. 
. 

as also liaised with  Dr -

. 

has advised  that as  part of the  extensive  work that was  undertaken 
Dr -
wheritneytook over the  practice, a retrospective  review of all  patient clinical  notes 
was undertaken. He explained that the issue around record keeping was that records 
,  were  poorly  "read  coded"  which  impacted  on  identifying  background  problems  and 
recalls . Read  Codes  are  a comprehensive  list of clinical  terms  intended  for use  by 
healthcare  professionals to describe  the  care and treatment given to patients. They 
include  signs,  sympto111s,  treatments,  investigations,  occupations,  diagnoses  and 
drugs  and  appliances.  Or  -
he  has  offered  assurance  that  FirsWay have 
mmarise all patients notes registered with the 
spent a lot of time and res~ 
practice  to  ensure they  were  as  up  to  date  as  possible.  We  also  understand  that 
Firsway  are  hoping  to  make  Gloucester  House  Medical  Centre  a  training  practice 
therefore they would  need to ensure records are correct and  kept up to  date  on  an 
ongoing basis. 

1 

The  new  systems  and  processes  in  place  outlined  in  the  supporting  information 
(Appendix One) offers further assurance  that there will  be ongoing improvements at 
the practice to maintain quality of care, in particular around patient safety. 

4. 

The  inquest  heard  that there  had been  concerns  locally within  the area 
about the  GP practice. They were now being  acted upon by the CCG but 
the  situation  had  been  an  issue  for  some  time  before  there  was 
intervention. 

4 

 t~1:ki 
Trafford 
Clinical Commissioning Group 

In  relation  to  Gloucester  House  Medical  Practice  specifically,  please  find  below  a 
timeline of events that occurred prior to the CQC inspection in August 2019. 

Gloucester House Medical Centre Timeline 

Summer2018 
In the summer of 2018 the CCG became aware of concerns about the GP 
who 
ran  2  practices  within  the  borough  of Trafford.  Old  Trafford  Medical  Practice  and 
Gloucester  House  Medical  Centre.  Primarily  these  concerns  were  related  to  the 
business side of the practice. Drlheld two different contracts a GMS contract (OTMP) 
and a PMS (GH) 

September 2018 

Followin~meetings  between  Dr I and  the CCG's Medical  Director,  Dr 
(MJ), 
agreed  for the CCG  to  undertake a "practice  diagnostic".  The diagnostic 
took place on·the 25th & 26th September 2018. The report made 14 recommendations, 
which were mainly organisational issues. The report concluded that the clinical care 
was  generally  safe  and  this  was  based  on  triangulating  a  number  of  nationally 
available  data sources. The report also  noted  that the  practices were offering  more 
appointments per 1000 population  than the evidence suggested, however the report 
advised Dr I to appoint two additional full time GPs. 

Autumn 2018-Spring 2019 
The diagnostic report was progressed with  an ongoing  action plan and overseen  by 
the CCG Head Primary Care, and .who initially met weekly with 
over time 
monthly.  From  the  time  of the diagnostic  in  September 2018  to  May  2019  normal 
practice  resumed. 
successfully  appointed  a  new  practice 
manager who commence!  employment atilie end of that month. 

In  January  2019  Dr 

I 

May 2019 
The CCG became aware of staff raising  more concerns about 
practice in  May 
2019,  in  particular  in  relation  to  the  financial  management  of the  practice  and  his 
commitment to the day to day running. In addition, this was at a time when Primary 
Care  Networks were being established and 
had become the Clinical Director of 
the North Primary Care Clinical Network. As the practice issues became an escalating 
situation, the CCG requested a Quality summit with  NHS England and the CQC, this 
is a review undertaken by a number of regulatory bodies to seek assurances around 
regulatory obligations. The practice was also part of the agenda's for the weekly 
Primary Care  MDT meetings  so  updates were provided  and  discussed every week 
whilst concerns were being managed. 

July-August 2019 
The Quality Summit took place  on  the 2nd  July 2019 and  the CQC  Inspections took 
place on the 7th July 2019 (OTMP) and 7 th  August 2019(GH). As a result of the cac· 

5 

 
 ,~1:..j 

Trafford 
Clinical Commissioning Group 

inspections,  Dr II; CQC  registration  was suspended from his Old  Trafford  contract 
meaning he would be unable to practice. In the case of GH his registration was not 
suspended meaning, whilst he could not practice he was still responsible for the day 
to day operational  running  of that practice,  including  the adequate  clinical  cover for 
patients 'registered at GH. The CCG were unable to intervene with recruiting with more 
GP's and other support generally as this was the responsibly of Dr

that time. 

Between August and the 30th  September 2019 
Dr l  had the right to appeal the CQC's decision to terminate his registration and duly 
started  to  do  so,  and  whilst  the  CCG  could  not appoint  a  care  taker  nor formally 
intervene in the day to day running of the practice (this remained the responsibility of 
the CCG did provide the usual general support which included engagement with 
the ANP directly to on a number of occasions for assurance around competence and 
that she would seek clinical supervision from the GP's in the practice if she felt unsure 
about any Issues. The CCG also provided additional Medicines Management support 
from the end of July to mid-September, primarily focusing on safety issues. This was 
over and above what a  practice this size would normally receive (3 days a week as 
opposed to one). 

During  the  period  between  early July and  September 2019  the  CCG  sought  legal 
advice and  in particular on the issuing of remedial  notices and the termination of Dr 
contract. The contracts were mutually terminated on the 3Q1h September 2019 

On  1st  October 2019 Firsway Medical Centre formally took over the contract to care 
take  Gloucester House  Medical  Centre  and  this  contract is in  place to this day and 
working well and engaging with the CCG on a regular basis in particular during the 
COVID-19 period. The CCG  is working with  NHSE to organise longer term  plans for 

the fractice. 

To  add  some  further  assurance  around  how  General  Practice  is  monitored  and 
regulated  we  have  provided  below  some  information  to  help  understand  how  this 
works, this 1includes our local arrangements within Trafford CCG. 

British General Practice is regulated by the Regulation of General Practice Programme 
Board (RGPPB) which brings together the bodies responsible for the regulation and 
oversight  of  general  practice  in  England.  The  board  comprises  of  11  separate 
regulators Including Care Quality Commission (CQC), NHS England and NHS Clinical 
Commissioners 

The CQC are responsible for the monitoring, inspection and regulation of services to 
make sure  they meet fundamental  standards  of quality and  safety and they publish 
that they find , including performance ratings to help people choose their care. GPs as 
contract holders are required to register with the CQC, typically these are the Partners 

6 

 
 t.!11ki 
Trafford 
Clinical Commissioning Group 

of a practice and the CQC have the right to cancel a GP's/practices registration should 
they find any breaches in the fundamental standards. 

NHS England have two roles, one of which is, to hold a contract with GP practices but 
delegate  the  management  of that  contract  to  the  relevant  Clinical  Commissioning 
Group  (CCG).  Their second  role  is  to  oversee  the  performance· of the  practitioner. 
They investigate complaints and manage fitness to practice concerns, an example of 
which,  might be  if they were  seen  to  be acting  outside of General  Medical  Council 
(GMC) regulations 

Trafford  CCG  manages  the  contracts  with  GPs,  there  are three  types  of contracts, 
General  Medical  Services  (GMS)  which  is  a  national  contract,  Personal  Medical 
Services (PMS) which is a  local contract,  and only a medical practitioner can  hold  a 
GMS contract. The final primary care contract is an Alternative PMS (APMS) contract, 
which  can  be held  by anyone,  they are typically used  for providers,  such  as Social 
Enterprises  who  provide  services  such  as  Out of Hours  Services.  These  are  time 
limited contracts 

The  CCG  is  also  responsible  for  the  monitoring  of quality of care  provided  for the 
healthcare  services  that  it  commissions.  To support this  there  has  been  a  Primary 
Care Quality Assurance and Improvement Framework (PCQAIF) in place since July 
2019. The framework describes two approaches to support ongoing Improvements in 
quality in GP practices in Trafford. 

Please  note that,  at this time  out of the  30 GP practices across the borough,"  2 are 
"Outstanding" (7%), 28 {93%) are rated as "Good with the Care Quality Commission 
(CQC).  The  CCG  engages  with  the  Trafford  CQC  Inspector  on  a  regular  basis 
(curr~ntly weekly) to gain updates on each other's work pr9grammes/visits which help 
inform any practice specific engagement and progress of improvement work. 

Within the (PCQAIF) there are two approaches to quality improvement: 

Reactive 

If a practice has a poor CQC outcome or if issues are identified that require immediate 
intervention, this is discussed at the weekly multidisciplinary team meeting (MDT) and 
actions agreed. 

Weekly Core MDT Membership 

•  Clinical Director of Quality 
•  Medical Director 
•  Commissioner 
•  Safeguarding/Nursing Representative 

7 

 ,~1:~1 

Trafford 
Clinical Commissioning Group 

. 

•  Performance and Quality Improvement Representative 
•  Medicines Optimisation Representative 

There could be occasions where subject matter experts will be required to attend the 
MDT, these include colleagues from Business Intelligence, Infection Control or 
Information Governance. 

There  are  key  actions  from  the  MDT  and  discussions  include,  levels  of  risk, 
engagement with the practice, development of action plans, and escalation to relevant 
senior committees eg: Senior Leader Team meeting at the CCG. 

Proactive 
This is the routine monitoring of practice profiles, these are individual profiles set up in 
the  CCG intelligence  system  "Tableau"  which  is the data system  that  holds  a  wide 
range  of primary care data, a sub-set of Indicators has been  determined to create a 
surveillance  dash  board  which  acts  as  an  Early  Warning  System  (EWS)  which 
indicates key areas to focus on to improve. 

The  EWS  has  been  developed  to  bring  together a  range  of available  routine  data 
sources  to  identify  those  practices  where  there  is  significant  variation  from  the 
expected values.  Data includes, secondary care,  prescribing,  progress of diabetes 8 
care process, QOF, list size changes and  patient GP surveys. 

Those practices with the  highest number of metrics showing significant variation are 
flagged  for  further  analysis  and  discussion  at  the  monthly  Primary  Care  Quality 
Assurance group (PCQAG), and whilst the data allows some indication where support 
may be needed, this is  not solely relied  on.  Soft intelligence is also gained from the 
PCQAG  members  prior to any engagement with a  practice  and  this  includes areas 
such as prescribing, safeguarding, and complaints. 

Engaging with Practices 

I 

Up to mid-March 2020 the Quality Team which  includes the CCG Associate  Clinical 
Director for  Quality and  the  Performance  and  Quality  Improvement  Manager were 
working to  a  2020  schedule of Quality Visits  with  all 30 practices in  Trafford  which 
were  prioritised  around  the  top  outlying  practices  in  the  (EWS)  as  well  as  those 
practices  who  required  additional  support  around  resilience  eg:  single  handed 
practices. 

This  approach was  working  well  to  build  strong  relationships  with  our primary care 
colleagues  and  discuss  their  challenges  with  us earlier  on  so  that  we  could  offer 
support where we  could  to maintain good quality services.  The intention was that all 
practices would have an onsite quality visit during 2020. 

As part of this work we are able to offer guidance on some external  support options 
on offer to practices and this was offered where appropriate including Local Medical 

8 

 ,~,:~1

Trafford 
Clinical Commissioning Group 

Committee  (LMC)  and  The  Greater  Manchester GP Excellence  Programme  which 
offers training opportunities to practice staff. 

The  COVID19  pandemic has meant that we have had to pause some of our quality 
work including the proactive practice visits while there have been focused work with 
our  practices  to  support  them  during  the  pandemic  in  prioritising  and  remodeling 
services to ensure patients are treated at the right time in-the right place. 

Now that we are moving  into the next phase of COVID  planning we will  be working 
with our colleagues in the CCG to develop the framework further following the 
pandemic so that it. is fit for purpose and continues to offer support to practices in a 
collaborative way whilst maintaining a level of assurance around key aspects of quality 
including  CQC  standards  and  National  and  Greater  Manchester  performance 
measures. 

Reporting and Accountability 

The Primary Care Quality Assurance Group (PCQAG) 

The  Primary Care Quality Assurance  Group  (PCQAG)  is  a fundamental  part of the 
Primary Care Quality, Assurance and Improvement Framework and all updates, 
themes  and  trends  from  quality  visits  are  reported  there.  The  group  seeks 
recommendations on appropriate actions to take relating to the practices identified via 
the  Tableau  Data  Surveillance  Group  and  other  sources  of  quality  intelligence· 
including Medicines Management, Safeguarding and Infection Control colleagues. 
Considerations  are  also  discussed  around  future  working  alongside  Primary  Care 
Networks to improve quality at Network level. 

TCCG  Primary  Care  Commissioning Committee  (PCCC),  Quality,  Finance  and 
Performance Committee (QFP) and Governing Body. 

-Summary reports are presented to the QFP  Committee and the PCCC by exception 
where there are specific areas of good practice to share, or where concerns have been 
raised. The committees  are  asked for approval  on suggested actions· put forward  to 
support  practices  to  improve.  Deep  dive  analysis  reports  are  also  provided  at the 
request of the committee as  required, and  a "Lessons Learned Report" in relation to 
Gloucester House Medical Centre was tabled at PCCC in February 2020. 

As sub-committees of TCCG Governing Body, escalation is decided on a case by case 
basis, usually by exception. 

9 

 ,~1:41 
Trafford 
Clinical Commissioning Group 

We hope our response is satisfactory for the issues raised, please do not hesitate to 
contact us should you require further clarification 

Dr-
Me~ 

r 

.__ 

10