Maurice Leech

From Maria Caulfield MP 
Parliamentary Under Secretary of State for Primary Care and Patient Safety 

39 Victoria Street 
London 
SW1H 0EU 

Ms Alison Patricia Mutch 
HM Senior Coroner, Greater Manchester South 
HM Coroner's Court 
1 Mount Tabor Street 
Stockport SK1 3AG 

18 November 2021 

Dear Ms Mutch, 

Thank you for your letter of 23 August 2021 to Sajid Javid about the death of Maurice 
Leech.  I am replying as Minister with portfolio responsibility for primary care and patient 
safety and I am grateful for the additional time in which to do so.  

I wish to begin by saying how saddened I was to read of the circumstances of Mr Leech’s 
death.  I can appreciate how upsetting losing a loved one during the emergency period of 
the COVID-19 pandemic must be and I offer my heartfelt condolences to Mr Leech’s family 
and loved ones.   

In preparing this response, my officials have made enquiries with NHS England and NHS 
Improvement (NHSEI), and the National Institute for Health and Care Excellence (NICE), 
and I will comment on each of the three matters of concern in your report.   

General practice 

I would like to acknowledge that general practice teams have worked tirelessly during the 
COVID-19 pandemic response, remaining open throughout and providing both face to face 
and remote consultations.  

In response to the pandemic, general practice teams rapidly changed how they provided 
support and delivered services to their populations, with a focus on triage and remote 
(telephone and online) consultations, so that they can see as many patients as possible, 
while minimising risk of infection from COVID-19 for patients and staff.  This approach was 
necessary to enable practices to manage demand and prioritise the most urgent cases 
and helped to navigate patients to the right services or healthcare professional at the right 
time.  The quality of care must remain the same high standard regardless of whether the 
appointment is in person or remote. 

 
 
 Throughout the pandemic, NHSEI provided guidance to general practice and continually 
updated standard operating procedures to ensure that changing services could operate 
safely.  NHSEI set out clear expectations that general practices offer face to face 
appointments alongside remote appointments (telephone and online), and that clinical 
appropriateness and patient preference should be taken into account to determine the 
most appropriate consultation method.  NHSEI has also supported general practices in 
how best to communicate with their population on how to access services.  Further details 
on guidance and standard operating procedures can be found on the NHSEI website1.  

General practices have been providing remote consultations to patients by telephone for 
many years to help patients access care and clinical advice quickly and conveniently.  
There are existing skills in the workforce when it comes to telephone consultations and 
telephone consultations are part of general practice training schemes.  NHSEI has worked 
with professional and regulatory bodies, voluntary, community and social enterprise sector 
(VCSE) and patient organisations to support the safe and effective use of remote 
consultations guided by the principle of the interests and preferences of the patient.   

A number of resources have been developed2 to support general practices with good 
practice principles in maintaining professional vigilance and identifying concerns around 
safety and safeguarding when using remote consultations.  The resources highlight the 
importance of ensuring patient safety, shared decision making, and patients’ needs are 
paramount.   

The Department and NHSEI continue to support general practice, as we emerge from the 
pandemic, to maintain and improve access to care for patients.  On 14 October 2021, the 
Government and NHSEI published Our plan for improving access for patients and 
supporting general practice3.  The plan includes investment of £250million in a Winter 
Access Fund to improve access to GP practice services.   

Hospital visiting 

I have noted your concern about the evidence given at the inquest into Mr Leech’s death 
that suggested his treatment and outcome could have been impacted because he was 
unaccompanied during his transfer and treatment at hospital.   

I would like to assure you that we recognise the importance of being able to accompany 
family, friends and loved ones in hospital.  A compassionate approach to facilitating 
hospital visiting is essential, balanced with the need to manage the risk of infection. 

Throughout the COVID-19 pandemic, national NHS England guidance on how NHS 
hospitals may choose to facilitate visiting was followed.  This was reviewed and updated 
regularly and outlined a set of principles on which local guidance should be based. 

1 Coronavirus » General practice (england.nhs.uk) 

2 See Annex  

3 Coronavirus » Our plan for improving access for patients and supporting general practice (england.nhs.uk) 

 
 
  
 
 
   
 
 
 
  
 
 
 
 
 The guidance advised that hospital visiting was suspended on 4 April 2020 to manage the 
risk of infection of COVID-19.  Visiting at that time was only permitted if a visitor was 
supporting someone with specific conditions such as dementia, a learning disability or 
autism, and where not being present would cause the patient to be distressed. 

From 5 June 2020, the number of visitors increased to a limit of one close family contact or 
somebody important to the patient.  However, where it was possible to maintain social 
distancing throughout a visit, a second additional visitor was permitted in certain 
circumstances; including a family member for individuals receiving end-of-life care.  

This guidance was most recently revised on 16 March 2021, which included guidance that 
in an emergency department the patient may be accompanied by one close family contact, 
or somebody important to the patient, to support the patient with complex/difficult decision 
making.  

Since the end of the national lockdown in England, visiting in hospitals is now subject to 
the discretion of local NHS Trusts, based on the national principles, which will make their 
own assessment as to the visiting arrangements that can safely be put in place.  Careful 
hospital visiting policies remain appropriate while COVID-19 continues to be in general 
circulation and organisations can exercise discretion where COVID-19 rates are higher.  
The health, safety and wellbeing of patients, communities and staff remains the priority.  

Fracture of the femur and pain management 

In relation to your concern about guidance for the treatment of fractures to the femur, you 
may wish to note that while NICE Clinical Guideline 124: Hip fracture: management4, does 
not make specific recommendations on the management of this type of fracture 
(periprosthetic), it does cover the use of analgesia (see section 1.4) and multidisciplinary 
management (section 1.8) of people with hip fracture.  I am advised by NICE that it is 
reasonable to expect that Clinical Guideline 124 could be applied to people with 
periprosthetic femoral fracture, such as Mr Leech. 

I am further advised by NICE that pain management of fractures is covered in NICE 
guidelines such as complex and non-complex fractures (NICE guidelines 375 and 386), and 
major trauma (NICE guideline 397), and that there is considerable professional and local 
guidance on the management of acute pain.   

Your report explains that Mr Leech was provided with palliative care on his return to the 
Thorncliffe Grange Nursing Home, and there is NICE guidance on palliative care for 
adults: strong opioids for pain relief (Clinical Guideline 1408), and for the care of dying 

4 Overview | Hip fracture: management | Guidance | NICE 

5 Overview | Fractures (complex): assessment and management | Guidance | NICE 

6 Overview | Fractures (non-complex): assessment and management | Guidance | NICE 

7 Overview | Major trauma: assessment and initial management | Guidance | NICE 

8 Overview | Palliative care for adults: strong opioids for pain relief | Guidance | NICE 

 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 adults in the last days of life (NICE Guideline 319).  NICE does not therefore agree that 
there is a lack of guidance in this area.  

I hope this response is helpful.  Thank you for bringing your concerns to my attention.  

MARIA CAULFIELD 
Minister for Primary Care & Patient Safety 

9 Overview | Care of dying adults in the last days of life | Guidance | NICE 

 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Annex   Resources to support general practice remote consultations 

•  Remote versus face-to-face: which to use and when? (Royal College of General 

Practitioners) 

•  Principles for supporting high quality consultations by video in general practice 

during COVID-19 (Royal College of General Practitioners and NHSEI) 

•  How to conduct written online consultations with patients in primary care (British 

Medical Journal) 

•  Key principles for intimate clinical assessments undertaken remotely in response to 

COVID-19 (NHSEI) 

•  Clinical safety risk templates to support general practice in mitigating risks 

associated with the implementation of digitally supported triage, online and video 
consultations 

•  Advice on how to establish a remote ‘total triage’ model in general practice using 

online consultations and e-resource on remote total triage model in general practice 
(NHSEI) 

•  Supporting practice staff with a Total Digital Triage model for online consultations 

and Admin Crib Sheet 

•  Top 10 tips for COVID-19 telephone consultations (Royal College of General 

Practitioners)  

•  Guidance for general practice on confidential enquiry questions for domestic abuse 

during a remote consultation (NHSEI and IRISI)

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

15 February 2022 

Alison Mutch 
Senior Coroner 
Coroner’s Court,  
1 Mount Tabor Street, 
Stockport  
SK1 3AG 

coroners.office@stockport.gov.uk 

Dear Ms Alison Mutch 

Re: Regulation 28 Report to Prevent Future Deaths – Maurice Leech, 30th April 
2020 

Thank you for your Regulation 28 Report dated 23rd August 2021 concerning the 
death of Maurice Leech on 30th April 2020. Firstly, I would like to express my deep 
condolences to Maurice Leech’s family.  

The regulation 28 report concludes Mr Leech’s death was a result of  
1a Frailty  
1b Peri-prosthetic fracture of right femur  
1c Fall  
II Chronic obstructive pulmonary disease, Type 2 diabetes, Heart Failure 

Following the inquest you raised concerns in your Regulation 28 Report to NHS 
England regarding: 

1.The inquest heard evidence that pre Covid, Mr Leech would have been examined
face to face by the GP rather than a telephone consultation without an examination.
The evidence indicated that a physical examination would probably have resulted in
Mr Leech being referred back to hospital at an earlier stage.

Telephone consultations have been in use in general practice for many decades to 
help patients access medical advice and care quickly and conveniently. Where 
studies have been conducted, telephone triage has been shown to be safe. 
Telephone consultations are part of general practice training schemes.  

The coronavirus (COVID-19) pandemic has brought about an unprecedented 
acceleration in the adoption of delivering NHS services remotely, and standard 
operating procedures have been produced to ensure general practice is able to 
operate safely in this context. The  relevant published version of the 
Standard Operating Procedure is here for reference which was iterated throughout 
the pandemic to meet changing needs and requirements since it was first published 

NHS England and NHS Improvement 

 in March 2020.  These procedures make it clear that general practices and Primary 
Care Networks should triage patients remotely (to determine the right person and 
timeframe for managing the problem) in advance wherever possible to help prioritise 
patient care based on needs; and that clinicians should determine the most 
appropriate consultation method with the patient - telephone, video, online, face to 
face. This should be determined by taking into consideration the patient’s 
preferences, needs (including accessibility, privacy, capacity and communication 
requirements), clinical circumstances and currently, local risks of COVID-19.  

In determining the most appropriate consultation method, considerations regarding 
patient safety, ability to make a satisfactory assessment, gain a sufficient 
understanding of the problem and whether information can be provided in a way the 
patient understands including assessing a patient’s understanding of the advice 
provided should be factors in determining the most appropriate consultation method. 
If a particular concern did arise following a remote assessment or remote advice 
being given, then a decision could be made to move to an alternative approach, for 
example, face to face consultation or for remote advice to be followed up in writing or 
with the patient’s permission with their carer.  

Professional guidance published by the General Medical Council sets out high level 
principles of good practice expected of everyone when consulting and or prescribing 
remotely for the patient https://www.gmc-uk.org/ethical-guidance/learning-
materials/remote-prescribing-high-level-principles and guidance to support shared 
decision making https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-
doctors/decision-making-and-consent. 

Additionally, guidance has been developed jointly between NHS England and the 
Royal College of General Practitioners (RCGP) on Remote vs Face to Face: which 
to use and when? and RCGP publish a range of guidance and learning materials on 
their Covid-19 Resource Hub .These resources underline the importance of ensuring 
patient safety, shared decision making and that an individual’s needs are paramount.  

Whilst we do not have all the clinical details regarding the circumstances of Mr 
Leech’s discharge, we would ordinarily expect there to have been communication to 
the GP, via a discharge summary from the hospital providing details of their 
assessment including examination and investigations, and for advice to be given to 
the patient about safety netting.  

Safety netting is a routine part of general practice consultations and explicitly sets 
out next steps to take for the patient in the event of a deterioration in their condition. 
The joint NHS England and RCGP guidance (linked above), which is now in place, 
refers to the importance of ‘safety netting’. Every GP practice must continue to 
provide face to face consultations alongside telephone, video and online 
consultations as part of making general practice as accessible as possible. 

2.Mr Leech was very vulnerable and a poor historian. Due to Covid he was sent 
alone to hospital and seen alone there. The evidence before the inquest was that if 
support had been available a more accurate picture of his baseline and needs would 
have assisted staff in treating him and potentially identifying that he should not be 
discharged back to the care home and that a fracture would not have been missed.  

 
 
 
 
 
 
 At the time of Mr Leech’s death, the national guidance around attendance at hospital 
settings “Visiting healthcare settings during COVID-19 pandemic.” The guidance 
restricted patients from attending appointments with a person to support them. In 
March 2021 this guidance was updated to advise that patients attending outpatients, 
diagnostic service and Emergency Departments are now allowed to be accompanied 
by one person to support them with making complex/difficult decisions. A link to the 
full guidance is included for information: Coronavirus » Visiting healthcare inpatient 
settings during the COVID-19 pandemic (england.nhs.uk) 

The following has been shared with NHSEI from Tameside and Glossop CCG.  

At the time of Mr Leech’s transfer to hospital at the height of the pandemic, North 
West Ambulance Service guidance aimed at minimising  the number of individuals 
within the patient compartment of an ambulance. Only essential escorts and the 
minimum number of clinicians to provide a safe level of care to the patient could 
remain in the patient compartment. This was to help to minimise the dispersal of 
respiratory secretions, reduce environmental contamination, and reduce virus 
particles in the air. Similar policies were in place for hospital A&E’s to reduce risk of 
transmission of Covid. 

Notwithstanding policies around escorting patients, ensuring that clear and accurate 
information travels with the resident is a crucial factor. There are two initiatives in 
place in Greater Manchester to this end. The ‘red bag scheme’ (described below) 
was already in place at the time of the incident, and an information sharing scheme 
referred to as the ‘GM Care Record’ (described further below) is currently at an 
advanced implementation stage.  

Tameside and Glossop CCG have implemented the red bag scheme for care homes 
with key information pertinent to the individual’s care. The bags are handed to 
ambulance crews and travel with patients to hospital where they are then handed to 
the doctor. Tameside and Glossop CCG had the red bag scheme in place across the 
patch at the time of the incident. Care home staff also hand over relevant information 
to ambulance staff to ensure they are aware of the individual’s needs to be passed 
on to the Emergency department. 

Greater Manchester has accelerated use of the GM Care Record (GMCR) to support 
data sharing between health and care professionals across the city region.  It means 
that all professionals involved in a patient’s care can share vital information across 
different organisations, settings and localities.  As well as informing clinical decision 
making at the point of care, the GMCR is also being further enhanced to support 
joined up care planning and coordination through a range of clinical use cases. 
Greater Manchester Health and Social Care Partnership are also continuing to 
develop the GMCR to include more data feeds between providers and supporting 
care planning and coordination through enhanced functions.  Social care information 
from across all 10 localities will also be added to the GMCR in Autumn/Winter 2021. 
Access to the GMCR can be made available to all relevant organisations that would 
have a requirement to access data, i.e. GP’s, acute trusts, council and private 
organisations. Access for private care organisations would be via a Data Protection 
Impact Assessment process, providing access to information in the GM Care Record 

 
 
 
 
 
 
 is based on a legitimate relationship to the patient and their care then, access can be 
discussed/provided via correct routes. 

3.The inquest heard that he was in significant pain from the fracture to the femur. 
Unlike the position relating to a fracture to the neck of femur there is no NICE 
guidance for treatment of such fractures to ensure a consistent approach to 
management of them in the elderly across the NHS. This included in Mr Leech’s 
case how to effectively manage his pain and the impact of that on his overall health. 

NICE has provided some guidance, Osteoporosis: assessing the risk of fragility 
fracture on the management of fragility fractures of the femur. In addition there is 
best practice guidance on fragility fractures in line with tariff management and patient 
pathways, available from the National Hip Fracture Database (NHFD), overseen by 
the Royal College of Physicians. This can be found in Guidance on the Operational 
Aspects of Best Practice Tariff for Fragility Hip Fracture Care. . NHFD are also due 
to recommend further best practice criteria including secondary prevention of such 
fractures. The ‘Best MSK Collaborative’ has a workstream on fragility fractures and 
the work steam is developing a recommended clinical and operational pathway for 
this group of patients (non-ambulatory fragility fractures) such that the approach of 
all the integrated systems will be consistent and reduce unwarranted variation. This 
includes pain management and we are expecting that the pathway will be shared 
with all Integrated Care Systems by the end of the year. The pathways are being co-
produced with the relevant specialist professional societies. 

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