Pardeep Plahe

ASHFIELD SURGERY

8 Walmiey Road
Sutton Coldfietd
B76 1QN

Appointments: 0121 351 7955
Telephone:

Fax: 0121 313 2509
Practice Manager:

Your Named Accountable GP is: 7 SY
Practice Code: M85026

25 February 2021

Our Ref: | |

Emma Brown

Area Coroner

Birmingham & Solihull Coroners Court
50 Newton Street

Birmingham

B4 6NE

Dear Emma Brown

RE: The late Mr Pardeep Plahe— DOB: 02-Feb-1988 DOD 12.8.20

Thank you for your request for further information in the Regulation 28 Report to see how we
are trying to prevent further recurrence of problems with Emis appointment screens not
refreshing.

I have enclosed our Induction Pack, which Page 4 highlights the issues with EMIS and the
steps that we take at Ashfield Surgery to address this. This is to ensure that all new members
of staff are aware of this. We have also discussed this with our nursing staff and our long-
term locums. This information has also been shared with our Primary Care Networks that use
EMIS currently, following the Coroners case.

Please find enclosed a Significant Event Analysis that was done shortly after the event. The
altered induction pack was updated IN January 2021. We have yet to receive a solution from
EMIS.

Yours sincerely

ASHFIELD INDUCTION 2021

Induction Process

On your first day you will have an induction with either the practice manager or deputy
practice manager. You will then have an induction with fone of the admin staff who will
go through the IT systems and ensure you have your logins and passwords. Following that
there will be time for you to sit with one of the doctors usually a salaried GP and also to
observe a trainee clinic.

Schedule

Surgeries/Clinics

© All trainees will have their own patient lists
* Currently during Covid these consultations will all be via telephone/video
consultation
« Appointment times will vary depending on your level of experience:
GP trainees
= Start on 30app minute appointments depending on level
= Reduce depending on level of experience in consultation with
supervising doctors or clinical supervisor
« Aim for ST2s to get to 15/20 minutes, for ST3s to get to 15 minutes
prior to CSA/RCA
«After passing exams ST3s should be reducing to 10 minutes to help
prepare for future clinical practice.
* When you are seeing patients the supervising doctor is available to review cases
o GP Trainees
= This may vary depending on your level of experience. We would
suggest for the first few weeks debriefing at the end of the clinic to
ensure that you are familiar with local procedures and protocols.

* Following each clinic you will have time allocated to complete administrative tasks
for the surgery such as referrals.

* You may also be allocated other tasks such as letters to review, results management
and medication management depending on your stage.

Private study

¢ GP trainees will have weekly sessions far private study.
o You are encouraged to complete portfolio, audit or arrange attending
secondary care clinics
« Audit
© Potential topics can be discussed with your clinical supervisor or the on-calf
doctor

° Hi available to support with developing data searches
© These are then presented at the clinical meeting or other practice meetings
and are a good opportunity to get involved with a topic you are interested and
helping to improve services
¢ Other suggestions that may be of interest:
© Observing specialist clinic within the practice can help to understand chronic
disease management, health promotion and prevention. This could include:
= Asthma/Diabetes or other chronic disease reviews
= Smears by the nurses
© Child imms clinic
= 6-week Baby checks or maternal postnatal checks
© For GP trainees this is a good way to observe prior to doing the
checks on your own if you aren’t already familiar with the
process
o You can also liaise with secondary care or community services to consider
opportunities for observing other specialist services or clinics

Meetings

« Practice meetings
o Take place every Friday from 1-2;30pm which you are expected to attend
o MDT meeting attended by all DNs staff and representatives from hospices
© There is a standard agenda which includes discussion of cases, safeguarding
issues, significant events and any other information which may need to be
communicated or discussed with the clinical staff
© Clinical cases discussed are usually complex cases where wider team input is
needed
«The supervising doctor may suggest you bring cases you review with
them to be discussed at the clinical meeting
= You are also free to bring any complex patients you think need a
wider review
« When discussing a patient please try to bring their EMIS number so
they can be recorded in the minutes in a partially anonymised way.

Tutorials

* Tutorials take place following morning clinics on Tuesdays with Dr HB ac on
Thursdays with Dr
* GPs are keen to cover topics of interest and related to General Practice
o Please feel free to make suggestions regarding areas you would like to cover
in future sessions

Clinic Guidance

Coding

* Coding in records helps to ensure there is a clear record of what has happened
o Using set codes helps with audit
© Itis also used to help with monitoring achievement in domains which affect
payment |.e.QOF/or ACE
* Because of this it is important that certain things are coded in the records such as:
© Clinical Problem
= This is within the consultation ~ it records the issue as an active
problem in the patient notes
= This helps with audit but also gives a useful indicator if a patient may
have been seen for the same issue before and may help to search what
has been done
© Chronic diseases
"This is important as it ensures patients get appropriate follow-up for
their long-term conditions
o Certain reviews — such as chronic disease/medication reviews
= This helps us to ensure that we are appropriately monitoring
/managing patients with various conditions

¢ Below is a list of some particularly relevant areas to be aware of with coding. If you
are unsure about any chronic disease coding please discuss it with the supervising
doctor as this will help us to ensure safe patient care,
o DNA/Failed Encounter

= Jf patients DNA, ensure these are documented onto their notes- “Did
not attend-no reason given”. Patients should be discussed within the
clinical meeting if they DNA 3 appointments in 1 year. This is to
determine how to action their DNA appointments.

o Carers

= If someone is a carer it needs to be coded as they will then be offered

support and an annual review
* Use the code-"Is carer”.
o Mental health

«if not sure what exactly the patient is presenting with code as
depressed mood, anxiety state, stress related problem or mental
health problem

= However if previous Dx on notes ensure when coding them that the
cade is put in as a “review” and not “first episode”, found under main
problem.

“When coding an initial depression diagnosis the patient must have a
review coded within 10-S6 days so ensure that you book follow-up or
advise the patient accordingly

o Asthma

= Ifa new diagnosis of asthma is being made patient should have
spirometry performed (during Covid Peak flow diary showing diurnal
variation is sufficient)

= If coding an old diagnosis please ensure the year of diagnosis is
correct otherwise this will flag as a new problem
o FGM
= if new must be coded. Discuss with Duty Dr to determine how to
code, review degree and report to outside agency.

Pink Pop up box

* Seen in right bottom corner during consultations
* Indicates if patients need:
o Long-term condition/Mental Health reviews
= Please note the depression review needs to be done between day 10
and 56 after diagnosis
« This needs to be coded as depression interim review +/-
depression medication review
o Cervical screening
= Please code as “Health education — cervical cytology” when advising
o  Immunisations
= Please code “Health education —imms” when advising
o Medication Monitoring
= Please advise patients if they need BP check, bloods or other
investigations
¢ Ifitis for diabetes please leave for routine diabetic check which
is being organised by the diabetic team (if you are unsure then
task/discuss with nurse Jo)
¢ During Covid - if BP check needed encourage to buy home
monitor but can be booked with HCA in purple clinic
o Smoking status/cessation advice
= Please code into notes and if smoking discuss cessation and code that
advice was given
© Please check this box during clinic and advise patients Check date of last
review in case is more recent and can advise to book in if over
* that they are due for the relevant investigations/reviews and document in notes
* Note annual review needed for some long-term conditions resets in April

EMIS Not refreshing

PLEASE ENSURE when you sign off,

that youlog back in to ensure that you haven’t had any other patients added to
your list as there can be late additions

Medication reviews/Repeat prescriptions

* We havea repeat prescription process and medication review process at the practice

¢ This is in the process of being updated but please see the attached policy for the
current procedures
« Key points
o When setting up a repeat prescription please ensure patients are stable on the
medication and up to date with relevant monitoring
o Ensure that a clear review date is indicated and there are an appropriate
number of issues to last until that time
o. Ifa medication requires monitoring or a condition review please note the date
of when that is due in the pharmacy/patient text when setting up to enable
colleagues to identify this easily
o Advise patients of the 48 hour turn around rule when requesting medication
and the need to attend for reviews when advised to ensure safe prescribing
o Ifyou are doing a medication review with a patient in clinic please ensure that
you have followed the process in that policy

Underline

Type 2 Diabetes diagnosis 4, Formatted: Font: (Defaut) +Body (Catibri), 12 pt, Hot Italic,
Formatted: Heading 2 —_ _ }

¢ _HBAic cannot be used to diagnose or monitor type 2 diabetes for patients with

thalassaemia, any haemoglobinopathy/Hb variant, HIV, end stage CKD or significant
anaemia (Hb<100)

¢__To diagnose T2DM in the above situations use fasting plasma glucose.

© [fasymptomatic_and FPG is >7 a second test is needed to confirm. This can be
done the next day or anytime after (there does not need to be a delay).

0. Ifsymptomatic and FPG is >7 then diagnose T2DM

o_If FPG is 5.6-7.0 then code ‘at high risk of diabetes’. Annual monitoring of FPG

will be required.

* For patients with diagnosed diabetes who cannot be monitored with HbA1c for the
reasons above use fructosamine tests to monitor diabetes. The fructosamine test
looks at control over last 2-3 weeks.

Prediabetes

lf Hbaicis between 6.0 and 6.4

Please code as pre-diabetes. They will need to be invited for an education session and
formally invited for a repeat HBA1c in 12 months

Use a template

These are available within EMIS and help to ensure all relevant or important information is
being gathered. They can also be useful for calculations such as QRISK or predicted peak
flow when relevant information has been input.

Most are optional but some (highlighted) should be used to ensure a complete review is
carried out or to ensure appropriate follow-up.

* Antenatal template — for all pregnant patients. Make sure to code the date for
pertussis vaccination (approximately 16/40) to ensure that we call the patients in at
the right time. Check their BMI any newly pregnant patient with a BMI 2 30, should
be prescribed 5mg folic acid for the first trimester.

* Mental Health Care Plan - This is an annual QOF requirement for all patients on the
Severe Mental Illness (SMI) register. If you are asked to speak to a patient for a
mental health care plan they should have been seen first by the HCA for a physical
health check which is also required. Please use the template to ensure that all
elements of the review are carried out and that it is correctly coded.

¢ Contraceptive template — optional — useful to make sure you get appropriate
information. There is a separate one for emergency contraception.

¢ Asthma template/Peak flow template — useful for predicted peak flows

* PHQ-3/GAD/6CIT — mental health assessments — useful to calculate and record in
emis

* QRISK2 - used to calculate and record in EMIS

During Clinic

Equipment

¢  Ineach clinical room there should be:

o Scales

Height measure
BP Cuff
Thermometer
Opthalmoscope/Otoscope
Peak flow and disposable mouthpieces
Urine dipsticks
Swabs and a selection of sample bottles
Blood form paper
Sample bags
Couch Rolls
Spare gloves
PPE Equipment for when seeing purple clinic patients
Speculums

oooo ogo 0000 0909000

Telephone Triage/Consultations

¢ Currently due to Covid all appointments will be via telephone or video consultation
unless otherwise specified by a doctor.

« The below resources may offer useful guidance on remote consultation:
o E-fh modules
= https://portal.e-ifh.org.uk/Component/Details/634669
= httos://portal.e-Ifh.org.uk/Component/Details/634673
= https://portal.e-ifh.org.uk/Component/Details/634689
o RCGP guidance
«  httos://www.england.nhs.uk/coronavirus/wp-
content/uploads/sites/52/2020/03/C0479-principles-of-safe-video-
consulting-in-general-practice-updated-29-may.pdf

Practice process
© Patients should be called twice with a minimum of ten minutes in between and leave
a voicemail if possible:
o. If they do not answer or call back then they will need to rebook
o Document in the notes that the encounter was failed and any follow-up if
needed
o Please consider if there is an urgent need for the appointment or a need to
contact the patient to remind them they need a review ~ mental health with
suicidal ideation, safeguarding issue, young child
¢ When calling a patient please check their DOB and address to confirm the identity
¢ We would suggest that you document that it is a telephone consultation due to
Covid in case of any future issues. (#telcov isa quick shortcut)
¢ If an interpreter is required then this should be done via language line (discuss with
reception managers)
© the patient should be booked as a double appointment once your
appointments are less than 40 minutes
* Patients can be called in for examination at our AMBER clinic if required (see below
for process)
© Please discuss all patients that you will be bringing in with the supervising
doctor to check it is appropriate prior to doing

Prescriptions
* Scripts are predominantly done via EPS (electronic prescribing) direct to a nominated
pharmacy.

© Scripts can also be sent electronically without a nomination to any pharmacy

© ach printer has a stock of FP10s in case paper prescriptions are needed
o Spare FP10 sheets are located in each clinical room in cupboard. Place some

into top draw of printer-FACE DOWN AND UPSIDE DOWN.

oO. If these run out then please liase with admin re: further supply

Examinations/AMBER

¢ You may be able to do some initial examinations remotely:
o Consider asking patients to self-examine:
™ Basic obs — Pulse/BP/Temp/Resp rate
*® May need support or equipment
» Cap refill — parents can do in children
= Peak flow

ic

o Consider using photos for:
= Rashes
* Lumps/bumps - unless intimate
= Swollen joints
» Wounds
o Consider video for:
* Brief neurological examination
* Joint pain to assess movements/gait
™ Assessment of acutely unwell patient (particularly children)
* Can check cap refill, respiratory rate, see if sunken eyes or
distressed

If you think a patient needs to be brought in for examination following a telephone
consultation this will be done at the practice within our AMBER site.
© We have 2 rooms running — one doctors, one nurses/HCAs
© PPE is required when seeing these patients
= Visor and Mask — sessional use (if seeing more than one patient in a
row please leave on)
™ Apron + Gloves — to be removed between patients
* Donning and doffing of PPE will be discussed in your induction
co Rooms and equipment should be cleaned down with Clinell Wipes/room
spray between patients
o Doctors are using
™ Basic supplies/equipment should be in the room
©. If possible then patients should be seen by the doctor who assessed them on
the phone
© The appointments are 20 minute slots to allow for cleaning down the room
and documentation (at present the computer in the room is not being used)
= Please keep assessment and explanation in the room to a minimum —
a follow-up telephone consultation can be arranged if needed
= When arranging the appointments
« Screen patients for Covid Symptoms
o Fever, Cough, Anosmia
o Check household contacts
* Advise patients:
o Not to attend if they develop Covid Symptoms
o They will be screened again at the door with a
temperature check
o Ask them to bring a face covering/mask
o Let them know they may have to wait outside if
another patient is in the room

Chaperones are still advised where appropriate:
o Only members of the admin staff who have completed chaperone training
should be asked to chaperone
o Ensure you acquire a chaperone for all intimate examinations. Ensure that
the chaperone is informed of what examination you are planning to perform,

Ensure you gain consent from the patient and explain the exam to the patient
and in front of chaperone.

Investigations

Lab Tests and Bloods
«Ifa patient wishes to have their bloods done at the practice, please discuss it with
the supervising doctor unless there is a note on the records.
¢ For patients having bloods at the practice :
o Complete the form via Test request section in EMIS (ICE)
= Test request> ontine test request> then select all
bloods/Swabs/Stool/GU/MC+Sofill out box with reason> continue
with request (bottom left green bottom)

© prior to printing and click proceed so that tests requested are filed in the
notes

© The results will automatically come back to the practice if we have requested
them

© Advise patients it may be 1- weeks to get the results and they will only be
contacted if there is a problem

© If they want to contact us to check the results, they can request online access
by emailing the practice and admin can arrange (please encourage this as
then they will be able to review bloods, request scripts and book
appointments) or they can call the results line between 13:30-14:30 daily
(note this is manned by a HCA so they may not be able to answer all the
questions).

«  {f patients need to do a sample during Covid
o Request using ICE as above
= NB
Requests for MSU with just haematuria written will be
rejected so if querying UTI then indicate
* GU swabs should be requested as HVS so that they will test for
conditions other than thrush
o ENSURE SAMPLES ARE LABELLED AND ADEQUATELY FILLED AND CLOSED
©. Print form (sticker paper goes in face down with stickers at the back) and
leave at reception with bottle/swabs
«if sample bottle please label, If swabs remind patient they must label
after they have done the sample
«The sample and the accompanying form should then be placed into a
plastic collection bag and to be sealed.
o Advise patient to drop sample back
o What to use?
= Stool sample pot-blue, sample needs to be up to second line
“Urine MC+S- red top bottle ( full to 10mts)

* Urine for ACR/Chlamydia - white top bottle
= White top bottle — universal collection — can be used for nail clippings,
sputum ete.
= swab — for wound swabs for ?infection
.
¢ These samples can be returned to reception
© NB-please ask patients to drop off between 12 and 3pm to allow for social
distancing with purple clinic

Sample Collection
« Samples are collected ~16:00everyday
* Samples received after this must be stored in the patients own fridge as we don’t
have refrigeration on site

© X-rays

¢ Currently due to Covid all X-ray’s are appointment based

«If referring to GHH please ensure all forms are SIGNED as otherwise patient will be

turned away
« See locations below for latest guidance during Covid
o Birmingham Chest Clinic
o Heartlands Hospital

* Patients must be referred
“Complete BHH radiology request form in documents
«Print and sign form
«Once completed give to referrals team to send

Ultrasound
¢ All except obstetric US are done via GHH
eH
¢ If US type not on the form you can free text and they will do
o. If unsure if it’s appropriate check with the supervising doctor
¢ Advise patients once US is done results should be back at the practice within ~2
weeks

CT/MRI

in response to the pressures of the radiology department at UHB following the COVID-19
pandemic, UHB restricted access to imaging for practices. The current access to imaging is:
+ All valid plain film requests are given appointments

+ All US requests need to comply with the new UHB imaging guidelines for ultrasound scans
+ No fluoroscopy (Barium studies), CT or MR requests directly into radiology

In response to recurring themes and discussions between UHB and the CCG, it is recognised
that there are some patients who do not fit into any specialty that you can contact to get
advice and guidance from secondary care colleagues. Examples for such cases include:
patients with weight loss not able to ascribe to any organ system; night sweats; and a

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patient with complex issues where an imaging, such as a CT scan, may help decide further
referral routes/management plans.

IF MRI SCAN

the safest way to request a scan is to either:-

(1) Contact Radiology secretary on 424 9416 between 1.00 and 3.00 (Mon-Fri) and ask for
Radiologist and discuss most suitable scan.

OR

(2) Send all requests viaA & G.

Acute referrals

Self-referrals
Patients can self-refer for specific services and do not require a Dr referral letter.
« Minor Eye Conditions Service
¢ Mental Health Talking Therapies )
o During COVID - central triage number for all talking therapies
o 0121 262 3555 - Open: 9am-11pm
* Screening and triage - Provided by Birmingham Healthy Mind Birmingham Healthy
Minds referral please contact 0121 301 2525

¢ Reach out recovery for Drug and alcoho! services in Birmingham.
0 https://www.changegrowlive.org/drug-alcohol-service-birmingham/central-
west
* Termination of Pregnancy
o Via BPAS - Patients to call 03457 30 40 30 — to book appointment or make an
enquiry

AtE referral
¢ Ifa patient needs to be seen in AtE then it is helpful to send a letter or copy of the
consultation to help the doctors when seeing them
«For Brief Summary -
© complete consult, document and save findings.
o Brief summary from Emis: Summary tab>Print>brief summary
« For Letter -
o Write using general referral template in documents and save to notes
* During Covid
o Print whichever option used to PDF

11

0 Save into AccuRx documents folder in Coronavirus folder on shared drive
co Use AccuRx to text to patient to take to hospital with them

Acute Medical/Surgical Referral

« Via Single Point of Access
o 0121507 3301

* You will speak to an ANP who will confirm details + where you want referral directed
©. If possible provide observations
o Ensure patients mobile number is correct before calling
o They will then text patient with details of where to go
o Email them a letter

« Can also be used for ENT hot clinic referrals

Mental Health Crisis Referrals
* Under 25s
o Refer to Forward Thinking Birmingham
o Call crisis team on
o Follow-up with letter — can write free text in comments section and task to
referrals team to send
¢ Over 25s
o Needs to be discussed via telephone via Mental Health SPA
" 0121 301 400 - Mon-Friday 8am-7pm (see form for OOH number)
«If under CMHT already — speak to duty team for that area
o Complete SPA referral form and task to referrals team to send

After Clinic

Referrals
e¢ When referrals are via digidictate

° 2WW

e Use NICE NG12 to help assess what meet the criteria for 2WW and discuss with the
supervising doctor if unclear

o  https://www.nice.org.uk/puidance/ng12

« Forms to be completed under document>create letter>search 2ww

¢ Some of the 2\ww referral letters have an information sheet for the patient which they
advise should be given to them prior to being seen. | also explain what the clinics
entail. Especially the breast Ca clinic; consultant r/v and ex, then USS/mammogram
{depending on age), +or — biopsy then final r/v with the consultant.

¢ Hand the form to Secretary tobe faxed and scanned on

General Referral

¢ Can be written in comments for general referral to a department.

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o Address generally to the department you are writing - ie “Dear Oncology
Colleagues...”
o Ensure that the referral is only written in one comment bullet point.

© Referral Forms
o Some departments/clinic have specialist referral forms to make it easier to
complete
o Find these from Document>create document>search... the below
= Antenatal Referral Form

* Need EDD
«Relevant PMH
° weight

™ Musculoskeletal
© BCHC - MSK Physiotherapy Referral Form
@ MSK Low Back pain Triage
«Mental Health
¢ Birmingham Healthy Minds Referral Form- for talk therapy
* Mental health psycho-geritrician referral- need to arrange
demetia screening blood
* Community Clinic forms
ENT ( hawthorns)
Gynae
Dermatology
Cardiology
© Palpitations referrals need ECG and baseline bloods
including
© Heart Failure referrals need BNP
o There is also a separate form for Direct Access
investigations

= Acute Clinics
¢ Rapid Access Chest Pain Referral UHB
* TIA_Clinic_Referral_Form_update GP

Advice and guidance
« during Covid to all referral or further investigations done via A&G
¢ Can be written in comments as per general referral or use advice and guidance
template in documents
e The response usually comes back within 1 week and will be sent to the requesting
doctor initially and forwarded to the referring doctor to action if it is not urgent.

Private referral letters
« We have a number of patients at the practice who have private health insurance and
they may ask for a private referral letter
« There is no charge for these letters, and we advise a turnaround of 7 working days.
* These documents are created DIGIDICTATE

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© These can then be printed out and left at reception for patients to collect or
tasked to admin to send on to patient electronically.

Other Clinic Administration

TWIMC letters

© These letters are for outside agencies such as universities, employers, council, etc.

¢ These can be written using the Document>create document>TWIMC

¢ There is a standard cost of

© Letters are only completed after patients have paid and they should be advised
itis a 7 day turn around once this has happened.

e {fa patient has financial issues and is unable to pay they should be advised to email
the practice for the attention of the management team and they can waive the cost if
appropriate.

Forms and certificates

* Patients may ask you about these during clinics
© Includes things such as medical certificates (not sick notes)/forms/insurance
forms
* These are completed by Salaried GPs but need to be priced by admin, then allocated
to one of the GPs
* If a patient gives you a form they want completing/asks about one these should be
handed reception
o Advise patients that they will be contacted regarding the cost and if they are
happy to pay that then they will be advised regarding the turnaround time.

Other Administration

LETTERS WORKFLOW

* This is a program used to process the documents that the practice receives from
secondary care and other outside agencies

¢ Each piece needs to be reviewed by a member of the Practice.

« The pieces sent to the doctors are clinical in nature and may require some form of
action.

© Prior to being allocated D you should have an opportunity to sit with one of the senior
GPs who can explain the process of filing and actioning documents

¢ You should expect to be allocated 15 letters/session

o When starting this will be a reduced amount

* When reviewing letters please also review notes on Emis to determine if requests have
already been actioned/coded

© Actions

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off following review of the letter a patient needs to book an appointment
« Add comment as to what it is regarding In free text and use the task
feature to either a secretary or Mrs abnormal results ( who
can then arrange an appointment
© This will forward to admin who will then message the patient to book an
appointment

¢ Medication Reconciliation
o Please note if patients have had medication changed whilst in hospital
o Ensure this is reflected in their repeat prescriptions
o Document in the notes what changes have been made

¢ Other admin
o Cervical SMEARS should be forwarded to Julie Merritt for action
o Filled out medical forms/certs/insurance forms-should not come to Drs -
forward to admi

Lab Results
You will receive specific training in a tutorial on managing lab results before you start doing
this. If you order a test youare expected to review

« Keynotes:
© Please review notes when looking at results to help inform decision making
and to check initial teeatment hasn't been started
© Ifresults are abnormal
* Comment on what is abnormal and plan so that reviewing doctor can
action
= Senda taskto Mrs Abnormal Results to book an appointment OR
« Send SMS via AccuRx asking to book a routine appointment
¢ if more urgent indicate time scale in message to help admin
¢ if cannot wait then call patient that day/discuss with
supervising doctor
= NB - if bloods have been done as part of an annual diabetic review
please do not message them to book a review unless urgent or a
condition that cannot be managed as part of the DIABETIC nurse review
appointment
°
0 Self-treatment
= Patients with Vitamin D insufficiency/Thrush etc can be sent a message
advising to pick up an OTC script with a patient information leaflet

regarding the condition
o. Ifyou are allocated smear results — please forward SC

e tab results coding
o Bowel cancer DNA’s

as

® Please send AccuRx “bowel screening test not done” template message
to patient

= Task results a follow-up

Medicine Management

© For GP trainees —
o During your placement you will receive training in how we issue repeat
prescriptions
o Once you have had training you will be allocated repeat scripts to issue with a
maximum of 10/day
of you are unsure of whether to issue a repeat or have any questions please
discuss with the supervising doctor or your trainer.

Useful Links
«= =Medicines complete
© Has online BNF and clinical calculators

© https://www.medicinescomplete.com/t

© Birmingham formulary
http://www. birminghamandsurroundsformulary.nhs.uk,

* NICE CKS
© Summaries on diagnosis/management of various conditions based on NICE
guidance

o https://cks.nice.org.uk/#?char=A

*  Patient.info
© Useful professional guidance and also good for patient leaflets
© https://patient.info

*® Primary Care Dermatology Society
o Useful guidance on diagnosis, investigation and management of various skin
conditions
0 http://Avnv.peds.org.uk,

@  FSRH
o Guidance on contraception
= General Guidance
e httos://www.fsrh.org/standards-and-guidance/fsrh-
guidelines-and-statements/

* MEC - contraception risk assessment
« http://ukmec.pagelizard.com/2016

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= COVID guidance
e = https://wiww. fsrh.org/fsrh-and-covid-19-resources-and-

information-for-srh/

¢ Versus Arthritis
o Useful patient exercise leaflets
0 https://Awww.versusarthritis.org/about-arthritis/exercising-with-
arthritis/exercises-to-manage-pain/

Useful Numbers

¢ SPA (OT, Physio, DNs, Bed bureau)- 0300 555 1919
¢ Mental Health SPA - 0121 301 4000 (8am-7pm)

¢ Forward Thinking Birmingham - 0300 300 0099

* Queen Elizabeth Hospital - 0121 371 2000

® Birmingham Children's Hospital - 0121 333 9999

© Good Hope Hospital - 0121 424 2000

COVID REFFERAL CENTRE,

‘The CRC is in the grounds of Highcroft Hospital and access is via Highcroft Entrance C which is
on the East side of Slade Road just North of the junction with Fentham Road. The address and
other instructions are on the booking confirmation after you have made the booking and you
need to pass this information to the patient.

* Please note there are currently no patient toilets on the site. Patients should be warned
about this and asked to bring a specimen of urine with them if possible, in a clean
container (if you think it is necessary).

* To book your patient in, click on this link: https://www.drivethrucare.uk/gp book.php
and then click on the button to log in

PRACTICE NUMBER_M85026
LOG IN password

REFERAL for pulse oximetry- for covid at risk groups and >65 COVID mz

17

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS

THIS REPORT IS BEING SENT TO: EMIS, Ashfield Surgery Sutton Coldfield, CCG, NHS England

CORONER

lam Emma Brown Area Coroner for Birmingham and Solihull

CORONER’S LEGAL POWERS

1 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.

ul

INVESTIGATION and INQUEST

On 19 August 2020 | commenced an investigation into the death of Pardeep Singh PLAHE. The
investigation concluded at the end of the inquest.

The conclusion of the inquest was Misadventure
1a HYPOXIC BRAIN INJURY

1b SELF INFLICTED INJURY TO NECK

1c

CIRCUMSTANCES OF THE DEATH

The Deceased died at the Queen Elizabeth Hospital on the 12th August 2020 after he inflicted a
catastrophic injury to his neck with a decorative samurai sword. He had become increasingly concerned
over recent weeks about a physical health complaint which had been discussed with his GP on the 6th
August and had caused him to attend the emergency departments of the Good Hope and Queen
Elizabeth Hospitals on the 8th, 9th and 10th August 2020. This culminated in a Urology Review on the
10th August 2020 where he was advised that further investigations were required and would be
arranged but there was no immediate cause for particular concern. Mr. Plahe had appeared to
understand the situation and had not given health care professionals any reason to suspect he would
harm himself. However, he had still appeared extremely anxious to his family. There was a missed
opportunity to review Mr. Plahe at 17:30 on the 10th August when he had been booked to have a
telephone review with a General Practitioner but due to a technical problem with the surgery’s computer
system, the practitioner was not aware of the appointment and therefore did not make contact. It is not
known what difference this review would have made

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. —

1. On the 10th August at 17:30, hours before he inflicted the fatal wound to his neck, Mr. Plahe had a
telephone consultation scheduled with his GP at the Ashfield Surgery. The appointment had been
booked by his sister that afternoon. Due to a technical issue with the EMIS system the consultation list of
the GP due to speak to Mr. Plahe did not update so he did not realise the appointment had been added
to his list and did not call Mr. Plahe. Practitioners at the surgery had realised that the system was
intermittently not updating consultation lists on or around the 30th July 2020 and had raised the issue
with EMIS on the 4th August 2020. To date a solution to correct this intermittent problem has not been
identified. Evidence was given at inquest that it does not just affect the Ashfield Surgery but has occurred
at other surgeries across the country.

2. Particularly for telephone consultations (where there will not be a patient physically present in the
surgery to query why they have not been seen), the fact that the consultation lists do not always update
creates a risk to life as a consultation could be missed for a patient with a medical emergency.

3. It is not known whether all GP Surgeries using EMIS have raised an alert that this error can occur.

4. To mitigate the risk of missing appointments the Ashfield Surgery has identified that if practitioners log
out of the EMIS system and then log back on the consultation list will update. Therefore, all practitioners
are advised to log out and log back in before completing their consultation lists. However, on one
occasion since Mr. Plahe's death a locum GP carrying out a list at the surgery did not know to do this and
missed an appointment.

5. The methods to mitigate this risk are vulnerable to human error if the practitioner is unaware of the
need to log out of EMIS and log back in or if they forget to do so.

6 ACTION SHOULD BE TAKEN

In my opinion action should be taken to prevent future deaths and I believe you have the power to take
such action.

7 YOUR RESPONSE

You are under a duty to respond to this report within 56 days of the date of this report, namely by 1
March 2021, 1, 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.

eect
Ihave sent a copy of my report to the Chief Coroner and to the Interested Persons.

lam 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.

9 4 January 2021

Signature ~~~

Emma Brown Area Coroner Birmingham and Solihull

Significant Event Analysis
incident Title: Suicide Patient and missed appointment due to EMIS not refreshing
Date of Review: 14/8/2020

Date of Incident:
10/8/2020

Present:

Brief Overview of Incident:

32 yr patient PP, Patient’s sister called for telephone appointment after a 111 callon
10/8/20 with anxiety relating to his pelvic issues having attended AE.

A telephone appointment was booked at 17:30 with discuss anxiety

Due to technical issues the appointment for Mididn’t refresh on[feppointment
screen. The patient appointment was missed.

We were contacted by the family on 13.8.20 and family discussed with They
informed that missed appointment and subsequently the PP committed suicide later that
evening with a samurai sword and had been admitted to UHB.

Hi informed Hl who contacted En evening 13.8.20. referred urgently to Cruise
Bereavement counselling. ¥ issued sedatives for family

Reviewing notes available

He had a pelvic, prostate problem and had been phoned on 6/8/20 and discussed with
| | recorded some anxiety nothing to suggest he would self harm- needed to
distinguish if musculoskeletal or pelvic and arranged a face to face appointment was
arranged with Hon morning of 10/8/20. (J tried to contact patient 2x - no
answer)

PP didn’t attend the appointment.

We had AE notifications that he attended GHH AE on 8/8/20 and 9/8/20.

Apparently on his own antibiotics and painkillers. Not clear what he was on or who
prescribed this. He also had a urology appointment and not clear from records who
arranged this.

Patient may have been in pain and concerned about sexual dysfunction but had
seen a urologist at UHB on 10,8.20and referred for further Investigation.

UHB report states known “ Peyronies disease as stated by patient, not seena urologist
for this previously. Not in retention, tender over perineum/ bulbar urethra and
referred for cystoscopy”

10.8.20 111 report - sister called report discussed anxiety didn’t declare any thoughts
of Self harm, no previous records of anxiety apart from stress in 2008 prior to an

exam.

Some concerns about genitals in 2004 but no urology referral.

Actions & Learning Points:

Investigation

Not clear what prompted this 32 yr old to take his life. No clear documented factors
that can explain why this happened.

At time of booking appointment issue was regarding anxiety relating to pelvic
problems. No references to self-harm.

Discussion :

Discussion amongst clinicians about whether further referral would be beneficial_as
patient had seen a urologist at UHB. Patient likely wanted further reassurance due to
anxiety related to this conditon

Need notes from hospital regarding admission after he self-harmed. We haven't been
informed by hospital of death. Unclear when he actually died in hospital.

Family requested notes, Bieereed, discussed with fi notes need to be checked to
remove any references to 3rd party.

Second issue was the problem with EMIS and not refreshing the appointments.
Bifhac highlighted this on 30.7.2020. Even manually refreshing the screen didn’t
highlight new patients added and literally had to logon and odd the system and
only then did patients appear. There have been other bugs with the IT system.
Hlpointed out these were escalated to EMIS on 4/8/20 byl

They suggested to check computer ports were open.

Action

We checked the ports were open witbyand Batter meeting but needed
independent check from IT department to get notes for family after check notes as
soon as possible

Chase up IT desk/Further escalation to IT desk.

Need notes relating to actual time of death to be chased up.

Bereavement card to family

Outcome
Manually need to log on and off as refresh the screening isn’t reliable to ensure
appointments not missed.

NHS Birmingham and Solihull 
Clinical Commissioning Group 
First Floor 
Wesleyan 
Colmore Circus 
Birmingham 
B4 6AR 

Telephone: 0121 203 3300 
www.birminghamandsolihullccg.nhs.uk  

9th February 2021 

Ms E Brown 
Area Coroner for Birmingham and Solihull  
Coroner’s Court  
50 Newton Street 
Birmingham 
B4 6NE 

Dear Ms Brown 

Re Report to Prevent Future Deaths – Pardeep Plahe  

Thank you for your e mail of 4th January 2021 with enclosed Regulation 28 Report to Prevent 
Future Deaths.  

I have made enquiries into the issues raised and can respond as follows.  

I understand that the issue of appointments not refreshing was raised as a concern by a number of 
GP practices. EMIS investigated and identified that this was due to the page(s) not refreshing if 
certain firewall ports were not opened or users were working remotely through a VPN (virtual 
private network) connection. The CCG’s IT Team were made aware of the problem around the time 
this incident occurred, and worked with EMIS and the GP practices to find a cause for the problem 
and a solution. Guidance was issued following the cause of the problem being identified.  

The most recent position has been checked by the CCG’s IT Team in light of your report, and I am 
advised that with the upgrade to Windows 10 there have a number of reports to EMIS of this 
problem reoccurring. In response to this information, the CCG has sent a communication to all GP 
practices highlighting potential problems and providing information on how this can be resolved, as 
well as providing them with contact details for the IT support service so that they can access 
assistance on resolving any ongoing problems. In addition, EMIS issued a safety advisory notice 
on 3rd February to alert practices to the need to identify and address this issue.  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 The CCG IT Team will continue to monitor the situation and work with both EMIS and the GP 
practices to identify and address any further problems.  

I hope these actions go some way to alleviating your concerns, but if you require any further 
information please do not hesitate to contact me.  

Yours sincerely  

Chief Executive Officer

Fulford Grange 
Micklefield Lane 
Rawdon 
Leeds LS19 6BA 
Tel: 0113 380 3000 
emishealth.com 

26 February 2021 

Ref: REGULATION 28 - 4 January 2021 (PSP) 

Dear Ms Brown, 

Please accept our regrets, with regards to the outcome of the situation detailed in the 
Regulation 28 report dated 4 January 2021. 

In light of this, a detailed review and investigation has been completed and is 
summarised below. This investigation has ensured that we fully understand the issue 
and are able to form a robust plan to remove the risk. 

A response to the five areas of concerns, outlined in the report, is provided below.  

Investigation Summary 

•  On 4 August 2020 (11:22) a staff member at Ashfield surgery contacted EMIS 

Support and raised case reference 
appointment book not refreshing. The Practice was advised to contact local IT 
and to ensure that the UDP ports 8088 - 0892 were fully open throughout the 
network. As no further contact was received from the Practice (after 72 hours) 
to inform the support team that this advice had not been successful, the case 
was closed and the Practice were advised of this.  

 due to an issue with their 

• 

In addition, the Practice raised a second issue on the same day, 4 August 
2020 (11:49), 
 relating to a clinician reporting they were getting a 
message on their PC alerting them that there was ‘Not enough memory’. The 
Practice was again advised to contact local IT as the issue related to 
hardware. Again, as no further contact was received from the Practice (after 
72 hours) to inform the support team that this advice had not been successful, 
the case was closed and the Practice were advised of this. 

•  A user-facing article relating to this issue was originally published February 

2020: 

Why isn’t my Appointment Book refreshing? 

Please find this article at appendix 1 of this letter.  

EMIS Health is a trading name used by members of the EMIS Group of companies 
which includes Egton Medical Information Systems Limited. 
Egton Medical Information Systems Limited is registered in England and Wales. 
Registered number: 02117205. Registered office: Fulford Grange, Micklefield Lane, Rawdon, Leeds LS19 6BA 

 
 
 Fulford Grange 
Micklefield Lane 
Rawdon 
Leeds LS19 6BA 
Tel: 0113 380 3000 
emishealth.com 

Concern 1 

•  On the 10th August at 17:30hrs, before inflicting a fatal wound to the neck, the 
patient had a telephone consultation scheduled with the GP at the Ashfield 
Surgery. The appointment had been booked by a relative that afternoon. A 
technical issue with the EMIS system caused the consultation list of the GP 
due to speak to the patient to not update and the GP did not realise the 
appointment had been added to the list and did not call the patient.  

•  Practitioners at the surgery had realised that the system was intermittently not 
updating consultation lists on or around the 30th July 2020 and had raised the 
issue with EMIS on the 4th August 2020. To date a solution to correct this 
intermittent problem has not been identified. Evidence was given at inquest 
that it does not just affect the Ashfield Surgery but has occurred at other 
surgeries across the country. 

Response 

•  The EMIS Web appointment book is kept up to date on a user’s PC through a 

combination of  

o  Periodically requesting updates from the EMIS Web data centre (which 

is always correct) 

o  Receiving updates from other PC’s whenever an appointment is 
booked. This mechanism uses ‘UDP messaging’ to broadcast 
appointments to all PC’s on the network to keep them up to date 

o  A manual ‘refresh’ capability is available in the appointment book to 
cover the eventuality of the UDP messaging not working. Customers 
have been informed that this is available to be used where there are 
concerns around refresh working 

•  UDP messages require specific configuration of the IT network to ensure that 

they can flow correctly. EMIS includes this as part of the standard 
configuration advice  

EMIS Health is a trading name used by members of the EMIS Group of companies 
which includes Egton Medical Information Systems Limited. 
Egton Medical Information Systems Limited is registered in England and Wales. 
Registered number: 02117205. Registered office: Fulford Grange, Micklefield Lane, Rawdon, Leeds LS19 6BA 

 
 
 Fulford Grange 
Micklefield Lane 
Rawdon 
Leeds LS19 6BA 
Tel: 0113 380 3000 
emishealth.com 

•  Following investigation, we can confirm that the surgery did raise the issue 
with the EMIS support team on 4 August 2020 and were provided with a 
resolution that they should contact local IT to ensure that the UDP ports 8088 
- 0892 were fully open throughout the network. 

•  We have found that a number of factors can contribute to network settings 
changing which cause UDP messaging stop working in other surgeries 
including Hardware updates to PCs. updates to the PC operating system 
(OS), NHS switch to Windows 10 or as local IT teams enforce new network 
policies to an entire organisation or locality. 

•  A user-facing article has been posted on the EMIS Customer portal to ensure 
they know to mitigate the risk and is available for self-help (KB0064144) to all 
customers: “Why isn’t my Appointment Book refreshing?”  The article was 
originally published before this incident (07/02/2020) and updated further on 
22/12/2020.  

•  The information feed, visible to all users when logging on to the EMIS Web 
system, was also updated to advise users to review the “Appointment Book 
refresh” notice on 23/12/2020. 

Concern 2 

•  Particularly for telephone consultations (where there will not be a patient 

physically present in the surgery to query why they have not been seen), the 
fact that the consultation lists do not always update creates a risk to life as a 
consultation could be missed for a patient with a medical emergency. 

Response 

•  The increase in remote working and telephone consultations has led to an 
increase in the number of users experiencing the issue.  It is not clear from 
the information available if the GP was physically at the Practice completing 
telephone consultations or completing these from a different location. 

•  Where a user is using a VPN (Virtual Private Network) to create an secure 
connection in order to login to EMIS Web from home, changes made to the 
Appointment Book at their workplace cannot automatically transfer via UDP 

EMIS Health is a trading name used by members of the EMIS Group of companies 
which includes Egton Medical Information Systems Limited. 
Egton Medical Information Systems Limited is registered in England and Wales. 
Registered number: 02117205. Registered office: Fulford Grange, Micklefield Lane, Rawdon, Leeds LS19 6BA 

 
 
 Fulford Grange 
Micklefield Lane 
Rawdon 
Leeds LS19 6BA 
Tel: 0113 380 3000 
emishealth.com 

messaging to their PC (or vice-versa). Users should regularly click the 
‘Refresh’ icon on the Appointment Book ribbon when working remotely. 

Concerns 3, 4 and 5 

• 

It is not known whether all GP Surgeries using EMIS have raised an alert that 
this error can occur. 

•  To mitigate the risk of missing appointments the Ashfield Surgery has 

identified that if practitioners logs out of the EMIS system and then log back 
on the consultation list will update. Therefore, all practitioners are advised to 
log out and log back in before completing their consultation lists. However, on 
one occasion since the patient’s death a locum GP carrying out a list at the 
surgery did not know to do this and missed an appointment. 

•  The methods to mitigate this risk are vulnerable to human error if the 

practitioner is unaware of the need to log out of EMIS and log back in or if 
they forget to do so. 

Response 

•  Due to home and remote surgery working due to COVID-19, we have noted 

an increase in reports of this issue. 

•  This has prompted EMIS to update its self-help information and to raise 
awareness of the issue via the article “Why isn’t my Appointment Book 
refreshing?”  As noted above, the article was originally published on 
07/02/2020 and was updated further on 22/12/20. In addition, the EMIS Web 
homepage information feed was updated to ensure this was visible to all 
EMIS Web organisations and users as of 23/12/2020.   

•  There is no need for users to log out and log into EMIS Web. The current 
advice is to use the ‘Appointment Refresh’ function whilst an automatic 
capability is developed and released. 

EMIS Health is a trading name used by members of the EMIS Group of companies 
which includes Egton Medical Information Systems Limited. 
Egton Medical Information Systems Limited is registered in England and Wales. 
Registered number: 02117205. Registered office: Fulford Grange, Micklefield Lane, Rawdon, Leeds LS19 6BA 

 
 
 
 
 Fulford Grange 
Micklefield Lane 
Rawdon 
Leeds LS19 6BA 
Tel: 0113 380 3000 
emishealth.com 

Summary of Actions  

A full clinical risk review has been completed and the following actions have been 
implemented or are in progress, to remove the risk of similar incidents occurring in 
the future: 

1.  Customer information feed – an advisory relating to the appointment refresh 

issue was prioritised to the top of the feed on 23 December 2020 and again on 2 
February 2021.   

2.  A Safety Advisory Notice (SAN 2021-005) advising organisation and users of the 
issue, the actions that need to be completed, and a link to direct them to further 
information if required was sent out to all GP Practices and Clinical Services on 3 
February 2021. 

3.  The development of a solution to mitigate the risk to all GP Practices and Clinical 
Services using the appointment book functionality is underway. This is estimated 
to be released early Q2 2021, this will: 

•  Provide an automated refresh for all the “Current day” appointments. 

•  Automatically refresh the appointment book at a pre-set interval if the user 
has not manually refreshed the appointment book within the specified 
timeframe. 

For example, if the pre-set refresh time is set at 10 minutes the 
appointment book will automatically refresh after 10 minutes if there has 
been no activity that would cause it to refresh within that time frame. 

•  Once completed, the functionality will be rolled out to all users in a 

controlled manner, to ensure it meets effectiveness and performance 
metrics. This approach is in line with usual processes for changes to 
functionality to ensure clinical safety and system performance is 
maintained. 

4.  A further review of the underlying appointment refresh technology is planned for 

2021. 

EMIS Health is a trading name used by members of the EMIS Group of companies 
which includes Egton Medical Information Systems Limited. 
Egton Medical Information Systems Limited is registered in England and Wales. 
Registered number: 02117205. Registered office: Fulford Grange, Micklefield Lane, Rawdon, Leeds LS19 6BA 

 
 
 
 Fulford Grange 
Micklefield Lane 
Rawdon 
Leeds LS19 6BA 
Tel: 0113 380 3000 
emishealth.com 

We trust that the details outlined above are of help. 

Finally, as a company we work very hard to support health care services across the 
UK and patient safety is of paramount importance to us. We were saddened to read 
of the issues relating to this particular incident and we would like to pass our 
condolences on to the family. 

If you have any further queries then please contact 
 in the first instance. 

 at 

Kind regards 

Chief Medical Officer, EMIS Group 

EMIS Health is a trading name used by members of the EMIS Group of companies 
which includes Egton Medical Information Systems Limited. 
Egton Medical Information Systems Limited is registered in England and Wales. 
Registered number: 02117205. Registered office: Fulford Grange, Micklefield Lane, Rawdon, Leeds LS19 6BA 

 
 
 
 
 
 Fulford Grange 
Micklefield Lane 
Rawdon 
Leeds LS19 6BA 
Tel: 0113 380 3000 
emishealth.com 

Appendix 1 

Why isn't my Appointment Book refreshing? 

Revised by 
• 

24d ago • 

 1642 Views • 

One of the key functions of your EMIS Web Appointment Book is that it is designed 
to automatically update to reflect changes made elsewhere in your organisation, so 
that you always have an up-to-date view of which patients are being seen, who’s in 
your waiting room, and what your availability and workload are going to be like. This 
function is called ‘Appointment Refresh’, and if it isn’t working it can lead to delays, 
missed appointments, and potentially a risk to patients. 

Unfortunately, the function doesn’t always work as it relies on network settings on 
your PC, and requires very specific configuration. These settings are out of our 
control and may even be locked down by your local IT support team. Therefore, if the 
function isn’t working it can be difficult for us to fix it straight away, as we may not 
have the access, or permissions, to change the relevant settings. 

What should I do if my Appointment Refresh isn’t working? 

In order for the EMIS Web Appointment Book to refresh properly, all PC's must be 
connected to the same physical and logical network, with the same subnet and the 
same IP range. In addition, the following firewall ports must be open on all PC’s: 

TCP port 8221 
UDP ports 8088 – 8092 

Your local IT team will know how to apply these settings; alternatively, our Service 
Desk can provide you with a small file which can be run on your PC to automatically 
apply the correct configuration – though, again, your IT team may have restricted this 
ability. 

EMIS Health is a trading name used by members of the EMIS Group of companies 
which includes Egton Medical Information Systems Limited. 
Egton Medical Information Systems Limited is registered in England and Wales. 
Registered number: 02117205. Registered office: Fulford Grange, Micklefield Lane, Rawdon, Leeds LS19 6BA 

 
 
 
 
 
 
 
 
 
 
 
 
 
 Fulford Grange 
Micklefield Lane 
Rawdon 
Leeds LS19 6BA 
Tel: 0113 380 3000 
emishealth.com 

My practice has a branch site, we’ve applied these settings but it’s still not 
working… 

Configuration across two or more locations can be slightly trickier – we have an 
application which we can install and configure in these instances. Call our Service 
Desk, explain your situation, and ask them about the ‘UDP Forwarder’ application. 
Be aware that our Service Desk analysts will need to remotely connect to the spoke 
servers situated at each location, and, depending on the complexity of your network, 
getting the configuration exactly right may take a bit of trial and error. 

What about appointments booked by external organisations? 

Appointments booked by external organisations via GPconnect will not automatically 
refresh in the Appointment Book this is because external organisations are not on 
the same physical or logical network. Externally booked appointments will appear in 
your Appointment Book view once this is next refreshed (either because of an action 
in your own organisation or if you manually refresh). 

My next clinic is about to start and I don’t have time to fix this right now – what 
can I do? 

If your Appointment Refresh isn’t working, you can manually refresh your own 
Appointment Book screen with the ‘Refresh’ button in the ribbon: 

EMIS Health is a trading name used by members of the EMIS Group of companies 
which includes Egton Medical Information Systems Limited. 
Egton Medical Information Systems Limited is registered in England and Wales. 
Registered number: 02117205. Registered office: Fulford Grange, Micklefield Lane, Rawdon, Leeds LS19 6BA 

 
 
 
 
 
 
 
 
 
 Fulford Grange 
Micklefield Lane 
Rawdon 
Leeds LS19 6BA 
Tel: 0113 380 3000 
emishealth.com 

My surgery/clinic/appointment session is ending - surely I can simply log off? 
It is particularly important to ensure that no additional appointments have been 
added before you finish your surgery. It's quite common for externally added 
appointments (e.g. NHS 111) to be added towards the end of the day, and there is a 
risk that these could be missed if your Appointment Book is not up to date. Please 
ensure that you manually refresh at the end of the surgery before finishing. 

I’ve never had this problem before, why has it started happening now? 
Updates to your PC, or changes to your operating system (OS) can alter your 
network settings. We’ve seen an increase in people reporting this issue as more 
NHS organisations are switching to Windows 10. Similarly, it’s possible that your 
local IT team may enforce new network settings to your entire organisation. 

Does the Appointment Book refresh automatically when working from home? 
It depends how you connect to your workplace network. 
If you are remotely logging onto a PC which is physically located at your 
organisation, the Appointment Book will continue to refresh automatically. The 
reason for this is that the PC you are connecting to is on the same physical network 
as other PCs at your workplace. 

If you are using a VPN (Virtual Private Network) to create an N3 connection and 
login to EMIS Web from home (e.g. you use an N3 Connect dongle from EMIS or 
Egton), changes made to the Appointment Book at your workplace will not 

EMIS Health is a trading name used by members of the EMIS Group of companies 
which includes Egton Medical Information Systems Limited. 
Egton Medical Information Systems Limited is registered in England and Wales. 
Registered number: 02117205. Registered office: Fulford Grange, Micklefield Lane, Rawdon, Leeds LS19 6BA 

 
 
 
 
 
 
 
 Fulford Grange 
Micklefield Lane 
Rawdon 
Leeds LS19 6BA 
Tel: 0113 380 3000 
emishealth.com 

automatically update on your PC or laptop (or vice-versa). The only way to ensure 
the Appointment Book is up to date is by clicking the 'Refresh' icon on the 
Appointment Book ribbon. 

Have you investigated other solutions, so this doesn’t happen in future? 
Given the increase in remote working that has occurred over 2020, we are looking at 
potential solutions to improve this functionality. Until we can implement a solution we 
will continue to investigate any instances of Appointment Refresh failure that are 
reported to us, and resolve those as best we can. 

EMIS Health is a trading name used by members of the EMIS Group of companies 
which includes Egton Medical Information Systems Limited. 
Egton Medical Information Systems Limited is registered in England and Wales. 
Registered number: 02117205. Registered office: Fulford Grange, Micklefield Lane, Rawdon, Leeds LS19 6BA

Miss Emma Brown, HM Area Coroner 
Birmingham and Solihull 
Coroner's  Court 
50 Newton Street 
Birmingham 
B4 6NE 

National  Medical Director  
NHS England  & NHS Improvement  
Skipton House 
80 London  Road 
London 
SE1 6LH 

29th June 2021 

Dear Miss Brown,  

Re: Regulation  28 Report to Prevent Future Deaths – Pardeep  Singh PLAHE, 
12th August 2020. 

Thank you for your Regulation  28 Report (hereafter ‘report’)  dated  4 January 2021 
concerning  the death of Mr Plahe on 12th August  2020.  Firstly, I would  like to express 
my deep  condolences  to Mr Plahe’s  family.  

The report concludes  Mr Plahe’s  death  was ‘by misadventure’  and that Mr Plahe 
died  as a result  of:   

1a Hypoxic brain  injury due to 
1b Self inflicted injury to neck 

Following  the inquest,  you raised  concerns in your report to NHS England  and NHS 
Improvement (NHSE/I) about  the following points,  in summary: 

•  An intermittent  technical issue  with the EMIS System which resulted  in a 
booked telephone  consultation  for Mr Plahe  with a GP, not taking place 
•  The potential  for this technical issue,  which does  not just  affect the Ashfield 

Surgery, to create a risk to life at other surgeries  across  the country. 

My Primary Care colleagues  have made enquiries  into the five specific areas  of 
concern and can respond  as follows: 

Concerns 1 & 2:  
•  On the 10th  August at 17:30,  hours before he inflicted  the fatal  wound to his 
neck, Mr. Plahe had  a telephone  consultation  scheduled  with his GP at the 
Ashfield  Surgery. Due to a technical  issue with the EMIS system the consultation 
list of the GP due to speak to Mr. Plahe did not update  so he did not realise  the 
appointment  had been added  to his list and did not call Mr. Plahe. Practitioners  at 
the surgery had realised  that the system was intermittently  not updating 
consultation  lists on or around the 30th  July 2020 and had  raised the issue with 

NHS England and NHS Improvement 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 EMIS on the 4th August 2020. To date a solution  to correct this intermittent 
problem  has not been identified.  Evidence was given at inquest  that it does not 
just affect the Ashfield  Surgery but has occurred at other  surgeries across the 
country. 

•  Particularly for telephone  consultations  (where there will not be a patient 

physically present in the surgery to query why they have not been seen), the fact 
that the consultation  lists do not always update  creates a risk to life  as a 
consultation  could be missed for a patient  with a medical emergency. 

Response 
The underlying  technical  issue  was with the EMIS system.  The EMIS system is part 
of the national  GPIT Futures  system and service framework between  NHS Digital 
and suppliers  of IT systems and services to GP Practices. 
NHS Digital  have advised  that EMIS are taking a number of actions “to remove the 
risk of similar  incidents  occurring in the future”.  I understand  that these  actions  have 
been  set out in the response  which EMIS provided  directly to the concerns raised.   In 
summary, these  actions  are: 

•  A Safety Advisory Notice (SAN) was sent  out to all GP Practices and Clinical 
Services on 3 February 2021,  advising  organisations  and users  of the issue, 
the actions  that need to be completed,  and a link to direct them to further 
information if required. 

•  EMIS also  included  this as a priority message  on the EMIS Web RSS 

(customer information) feed. 

•  Development  of a solution  to mitigate  the risk to all GP Practices and Clinical 

Services using  the appointment  book functionality.    

Given the action  already being  taken by EMIS, my Primary Care colleagues  consider 
that there  is no further action for NHSE/I to take at this time. 

Concern 3: 
• 

It is not known whether  all GP Surgeries using EMIS have raised an alert  that this 
error can occur. 

Response 
EMIS have identified  in their response  to you “an increase  in reports  of this issue” 
and noted  that they have updated  their self-help  information, raised  awareness  of the 
issue  via the article “Why isn’t my Appointment  Book refreshing?”  and updated  the 
EMIS Web homepage  information feed in order  “to ensure  this  was visible  to all 
EMIS Web organisations  and users  as of 23/12/2020”. 

Concerns 4 & 5: 
•  To mitigate  the risk of missing appointments  the Ashfield Surgery has identified 

that if practitioners  log out of the EMIS system and then  log back on the 
consultation  list will update.  Therefore,  all practitioners  are advised to log out and 
log back in before  completing  their  consultation  lists. However, on one  occasion 
since Mr. Plahe's death  a locum GP carrying out a list at the surgery did not know 
to do this and missed an appointment. 

 
 
 
 
 
 
 
 •  The methods  to mitigate  this risk are vulnerable  to human  error if the practitioner 
is unaware  of the need  to log out of EMIS and  log back in or if they forget  to do 
so. 

Response 
Following  Mr Plahe’s  death, the Ashfield  Surgery carried out a Significant  Event 
Analysis  (SEA) to identify learning  and actions  to avoid the risk of similar incidents.    
I am advised  that,  as a result,  the practice highlighted  in their  induction  packs for GP 
trainees  and locums the screen  refresh issue  and instructions  to log out and back in 
to the EMIS system. 

Further  mitigation  of the risk, for all affected practices, will be addressed  via the 
action being  taken by EMIS to develop  a solution  within the EMIS System, as set out 
in EMIS’s direct response  to these  concerns.  This  solution  is expected to be 
released  in September 2021.   I have been  advised by NHS Digital  that, by way of 
assurance,  they have agreed  with EMIS that the  solution  will be reviewed jointly  by 
NHS Digital  and EMIS clinicians. 

Given the action  already being  taken by EMIS to develop  and roll-out  a solution  to 
the identified  issue,  my Primary Care colleagues  consider  that there  is no further 
action for NHSE/I to take at this time. 

Thank you for bringing  these  important  patient  safety issues  to my attention  and 
please  do not hesitate  to contact me should  you need any further information. 

Yours sincerely, 

National  Medical Director