Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0201, written 11 Jun 2021. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 11 Jun 2021 |
|---|---|
| Reference | 2021-0201 |
| Deceased | Brian Mottram |
| Coroner | Alison Mutch |
| Coroner area | Greater Manchester South |
| Category | Community health care |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Tameside Clinical Commissioning Group. CORONER 1 I am Alison Mutch, Senior Coroner, for the Coroner Area of Greater Manchester South. 2 CORONER’S LEGAL POWERS I 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. 3 INVESTIGATION and INQUEST On 16th November 2020 I commenced an investigation into the death of Brian Mottram. The investigation concluded on the 26th May 2021 and the conclusion was one of; Narrative: Died from Covid 19 pneumonitis not diagnosed until after his death contributed to by his previous necessary surgery for lung cancer caused by a combination of smoking and asbestos exposure during his working life. The medical cause of death was 1a Covid 19 Pneumonitis; II Chronic Obstructive Pulmonary Disease, Ischaemic Heart Disease, Previous Right Upper Lobe Resection for Lung Adenocarcinoma, Type 2 Diabetes Mellitus. 4 CIRCUMSTANCES OF THE DEATH On 15th November 2020, Brian Fredrick Mottram was found unresponsive at his home address, Markham Street, Hyde. He had been feeling unwell for over a week. On 13th November 2020 he had a telephone consultation with the GP. He reported shortness of breath, a cough, a tight chest, feeling hot and cold and not eating. He was not seen face to face and he was prescribed antibiotics. Post mortem examination found that he had died from Covid 19 pneumonitis. He was at risk of complications of Covid 19 due to his underlying health issues including diabetes, chronic obstructive pulmonary disease and a previous lobectomy for lung cancer. The lung cancer was due, on the balance of probabilities, to a combination of smoking and asbestos exposure during his working life. 1 5 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. The inquest heard that the GP surgery in common with surgeries across Tameside had a policy of predominantly using telephone appointments rather than face to face or video appointments. It was accepted at the inquest that Brian Mottram’s symptoms were consistent with Covid 19 but not there was no evidence before the Court that they were considered as such by the GP. A face to face appointment and testing in such a scenario may well have led to identification of Covid 19 and different treatment. 2. It was unclear during the inquest how GPs in Tameside were identifying high risk potential Covid 19 cases or the tools that they had to assist with identifying when to bring in for additional assessment patients who were particularly vulnerable to the effect of Covid 19 to check, for example oxygen levels consistent with silent hypoxia. 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 6th August 2021. I, 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. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely the family of the deceased, who may find it useful or of interest. I am 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, 2 the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 9 Date: 11th June 2021 Signature: Alison Mutch HM Senior Coroner 3
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
CHIEF EXECUTIVE Chief Executive, Tameside MBC and Accountable Officer, Tameside & Glossop CCG Tameside One, Market Place, Ashton under Lyne, OL6 6BH www.tameside.gov.uk Call Centre 0161 342 8355 Date 24 June 2021 Strictly Private and Confidential Alison Mutch OBE HM Senior Coroner Dear Ms Mutch Re: Mr Brian Mottram - Regulation 28 Report to Prevent Future Deaths Further to your letter, dated 11 June 2021, regarding the tragic case of Mr Brian Mottram please find my response outlined below. The untimely death of a person is distressing for their family and any others affected by their death and loss, and all the more so if there is any belief that but for the actions of any organisation it could have been avoided. I would like to record my sincere condolences to the family of Mr Mottram for their loss and I hope through this process they can obtain some closure. The matters of concern raised with the Regulation 28 Report to Prevent Future Deaths were as follows: That Tameside and Glossop general practices had a policy of predominantly using telephone appointments rather than face to face or video appointments; that as Mr Mottram’s symptoms were consistent with Covid-19, with no evidence they were considered as such by his GP, and that a face to face appointment may have diagnosed Covid-19 and different treatment put in place; It is unclear how GPs in Tameside were identifying high risk potential Covid 19 cases or the tools that they had to assist with identifying when to bring in for additional assessment patients who were particularly vulnerable to the effect of Covid 19 to check, for example oxygen levels consistent with silent hypoxia. Since the advent of the Covid-19 pandemic general practice has been delivering health care services according the national General Practice in the Context of Coronavirus Standard Operating Procedure that has been regularly updated. At the time of Mr Mottram’s death primary care was following the guidance in Version 3.4, which was published on 24 June 2020. The aim of this Standard Operating Procedure was to ensure general practice was able to provide health care to patients in a safe environment, limiting the opportunity of Covid-19 infections in staff and patients. The aim was to reduce the number of absences either by infections or self-isolation. The General Practice in the Context of Coronavirus Standard Operating Procedure v3.4 stated that practices should be open for delivery of face to face care, whilst triaging patients remotely in advance where possible, using remote consultations where appropriate. To support this national guidance Tameside and Glossop CCG also developed the Tameside and Glossop CCG/LMC GP Guidance, which is updated monthly. At the time of Mr Mottram’s death v19, October 2020, was in force. This guidance provides practices with routes to manage patients who require consultations based on whether they have covid symptoms or not. The Tameside and Glossop CCG/LMC GP Guidance v19 states that patients suspected of having Covid-19 should be remotely triaged by telephone or video. This would be carried out in the first instance by NHS 111 or the Covid Clinical Assessment Service (CCAS). The process to be followed if the remote triage had assessed Covid-19 as the most likely source of symptoms was risk stratified by low, modest, moderate or high risk. Low risk patients would be advised to stay at home; modest risk patients to call the practice or NHS 111 if their symptoms worsened; moderate risk would be provided with an oximeter to measure the oxygen saturation with a 24 – 48 hour phone / video review by the practice of the out of hours Primary Care Access Service; high risk patients, if severely unwell were advised to ring 999 or assessed by the Tameside and Glossop Digital Health team who would arrange admission if required. Between April 2020 to March 2021 Tameside and Glossop general practices have delivered over 1 million appointments, this includes 563 286 (or 51.6%) face to face appointment and 19,096 home visits. In April 2021 there were 99 350 GP appointments in Tameside and Glossop - 55 116 (55.47%) were face to face, 42 454 (42.73%) were by telephone with 1694 (1.7%) home visits. The current national guidance states that practices should still triage all patients, and while Covid- 19 is still a risk, a balance is still required to ensure the safety of staff in general practice, while ensuring that patients can still have consultations. This blended approach has seen more appointments in Tameside and Glossop taking place face to face than remotely. This blend of face to face and remote consultations was NHS England policy before Covid-19, but necessity caused by the pandemic accelerated this. However, the CCG has been mitigating any potential harms that may occur as a result by encouraging practices to see patients face to face where clinically appropriate and will continue to do so. As the pandemic evolves, so too will the national, regional and local guidance. The CCG has commissioned a Covid Home Oximetry Management Service to monitor COVID-19 positive patients considered mild or moderate risk in the community who can be safely managed at home to: Provide safe care at the right time in the right setting, with a focus on safely managing patients at home and escalating promptly, those who require community or hospital treatment Improve patient outcomes, with a specific focus on reducing mortality Escalate cases of deterioration at an earlier stage, thereby providing hospital treatment promptly and reducing in-hospital length of stay Patients are referred into the service by their GP or by Tameside and Glossop Integrated Care Foundation Trust as part of their step down approach from the Emergency Department, the Acute Medical Unit and Clinical Decisions Unit. Patients are referred into the service if they have raised concerns with their GP, NHS 111 have booked them into it or a practice has received a positive result and is concerned about the patient’s risk factors or vulnerabilities. Once referred into the service, patients are further assessed and classified as either low risk, appropriate for home oxygen monitoring or very unwell. Low risk patients are provided safety netting information, while those appropriate for home oxygen monitoring are provided with an oximeter and information on how to use it and report their oxygen saturation levels three times a day. Those who are very unwell are admitted to hospital via 999. Patients are monitored for 14 days after the onset of their symptoms, unless the patient feels they are getting worse, where they will be admitted to hospital. After 14 days of symptoms not worsening the oximeter is collected. The Covid-19 pandemic is constantly evolving and all health care settings are evolving with it, adapting to each changed circumstance to deliver health care services safely for both patients and those working within the health and social care system. Tameside and Glossop CCG shall continue to develop and support safe ways of working alongside its providers, learning from all adverse events. I hope that we have provided you with the necessary assurances in relation to your concerns. Please contact me if you require any further information or if I can assist further in any way. Yours sincerely Chief Executive, Tameside MBC/Accountable Officer, Tameside & Glossop CCG
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