Alexander Theodossiadis

Kevin Mcloughlin 
Senior Coroner 
West Yorkshire (Eastern) 
Coroner's Office and Court 
71  Northgate 
Wakefield 
WF1  3BS 

Dear Mr Mcloughlin, 

•Department 

of Health &
Social Care 

'}Ji,rt.. November 2022 

Thank you for your letter of 3 December 2021  to the then Secretary of State, Sajid Javid, about 
the  death  of  Alexander  Theodossiadis.  I  am  replying  as  Minister  with  responsibility  for 
Secondary care and thank you for the additional time allowed. 

Firstly,  I would  like to  say  how deeply saddened  I was  to  read  of the  circumstances of Mr 
Theodossiadis' death.  I can appreciate how distressing his death must be for his parents and 
those who knew and  loved  him,  and I offer my heartfelt condolences.  It is vital that we take 
the learnings from what happened to prevent future deaths and improve the NHS. 

In  preparing this response,  Departmental officials  have made enquiries with  NHS  England, 
the National Institute for Health and Care Excellence (NICE), as well as the relevant regulation 
in this case, the Care Quality Commission. 

General practice is the cornerstone of our NHS and the Government is committed to helping 
staff deliver for patients.  We knew before the pandemic that general  practices were under 
pressure and that patients were finding it difficult to access services.  That is why, in 2020, we 
announced  a  £1.5  billion  funding  to  create  an  additional  50  million  general  practice 
appointments  by 2024,  by  increasing  and  diversifying  the workforce.  In recognition  of how 
challenging the past two years  hav~ been for general practices we made an additional £520 
million available to improve access and expand general practice capacity during the pandemic, 
and  in October 2021  we published our plan1 for improving access for patients and supporting 
general  practice.  The  plan  included  actions  to  increase  and  optimise  capacity,  address 
variation and encourage good practice and improve communication with the public. 

One key aspect included in the plan was putting in place arrangements that enabled all general 
practices to  use Microsoft Teams telephone functionality for outbound calls, freeing up lines 
for incoming  calls.  The  longer-term  aim  is to  drive  the adoption  of cloud-based  telephony 
across all  practices which will  bring  benefits that support practices to improve call  handling 
and support patients to get more timely access to appointments. 

I am incredibly grateful for the contribution  of GPs  and  their teams  over the  last two years, 
who  stepped  up  to  deliver  our world-leading  vaccination  programme  while  still  providing 
exemplary care for their patients during a pandemic.  However, we know that general practices 
are very busy and remain under huge pressure.  General practice appointment numbers are 
above pre-pandemic levels, excluding appointments for Covid-19 vaccinations, there were on 

1  https://www.england.nhs.uk/coronavirus/wp-content/uploads/sites/52/2021/10/BW999-our-plan-for-
improving-access-and-supporting-general-practice-oct-21.pdf 

 
 average  1.30 million general  practice appointments  per working day in  June 2022,  a 6.0% 
increase from  June 2021  (1.22  million).  The  proportion  of face-to-face  appointments  have 
also steadily increased from a low point of 46.8% in April 2020 to 64.8% in June 2022. 

As we emerge from the pandemic response,  it is vital that Government continues to monitor 
and assess how best to support general practice as we have done throughout the pandemic 
to provide the best possible care for patients. 

Good access to general practice services is not just about getting a timely appointment,  it is 
also about access to the right person,  providing the right care,  in the right place at the right 
time.  There have been big changes to the way that much of healthcare operates over the last 
two years, and general practices have adapted and changed their ways of working to continue 
providing vital services to their communities.  One key change has been the wider adoption of 
remote triage approaches - the process by which patients contacting their general practice are 
assessed before an appointment is made, so that they are able to access the most appropriate 
support. 

Triage will continue to improve and offer long term benefits for patients and practices.  NHS 
England  have commissioned  an  independent evaluation  to  understand  the impact on staff, 
patients and the wider health and care system of using digital tools and triage approaches in 
general practice to inform its long-term strategy. 

Under  general  practice  contract  arrangements, 
it  is  ultimately  the  responsibility  of 
practices/contract holders to determine what training staff need and ensure that their staff are 
appropriately trained to a level that keeps staff safe and meets the needs of patients using the 
service.  The  British  Medical  Association  has  guidance  to  help  general  practitioners  and 
practice  managers  make informed  decisions  about what mandatory  and  statutory training 
general  practice  staff  should  do.  The  regulator,  the  Care  Quality  Commission  is  the· 
appropriate body that considers whether practice staff have the right qualifications, skills and 
knowledge  and experience to  do their job, how the practice identifies the learning  needs of 
staff, and whether they have adequate training to meet the learning needs. 

The 2016 General Practice Forward View strategy2  provided support for practices to build the 
capacity and capabilities required to meet patients' needs.  As part of the GP Forward View, 
the  five-year General  Practice  Development  Programme  was  established.  It included  total 
funds  of £45 million for allocation by Clinical Commissioning Groups to general practices for 
training  of  reception  and  clerical  staff  to  undertake  active  signposting  and  document 
management.  The active signposting training included an  expectation for receptionists to be 
skilled and confident in sensitively ascertaining the nature of the patient's need and exploring 
with them safe and appropriate options, including sources of advice and  support outside the 
practice as  well  as within.  Further features  of the  signposting training  includ~d  a  focus  on 
recognising red flag symptoms which require urgent medical attention and skills development 
to ensure staff are confident in communicating  care options. 

The NHS Long Term Plan. published in 20193,  sets out further ambitions for general practice 
and builds on the ambitions in the GP Forward View. 

NHS  England  (NHSE)  is  continuing  to  provide  support  to  practices  working  in  the  most 
challenging  circumstances  via  their  Accelerate  Access  Improvement  Programme.  This 
programme has been supporting practices to develop tailored  improvement plans,  including 
making appropriate use of digital tools, matching capacity to demand and making best use of 
multidisciplinary teams to improve access for patients 

2  https://www.england.nhs.uk/wp-content/uploads/2016/04/gpfv.pdf 
3  https://www.longtermplan.nhs.uk/ 

 I understand from the local NHS Leeds Clinical Commissioning Group (CCG),  which  from  1 
July 2022,  became  part of the NHS West Yorkshire  Integrated  Care Board  (ICB) that it will 
,  continue to review the access arrangements for the particular general practice and implement 
learning  from  the  incident  and  other  patient  feedback  in  relation  to  obtaining  timely 
appointments.  The ICB is working on improving care access and has established a steering 
group to review patient pathways and the training of receptionists in care navigation, including 
integration measures with urgent care services. The ICB is reviewing the recording of incidents 
to ensure mechanisms to share learning are implemented to improve quality of care. The lCB 
is  also  prioritising  investment  in  training  for  practice  staff  on  red  flag  symptoms  such  as 
meningitis and sepsis. 

· 

With  regard  to the  issues that you raise  related to the treatment of Mr. Theodossiadis  in  the 
hospital,  my  officials  have  informed  me  that  Leeds  Teaching  Hospital  NHS  Trust  has 
conducted  a  serious  incident  report.  As  a  result,  a  root  cause  analysis  meeting  was 
undertaken 3 days after the incident, which had considered the clinical care of the patient in 
the emergency department, including the decision around undertaking a lumbar puncture; the 
organisational issues around the CT;  handover care; and the management of the patient by 
the receiving ward, including falls assessment. 

· 

The  route  cause  analysis  identified  areas  for  action  in  that  handover  and  transfer 
communication  be  improved  to meet the  standard  of existing  Trust's policy,  as  well  as  the 
introduction  of a  digital  handover  tool  to  supplement  telephone  communications,  and  to 
address  the  mismatch  between  Trust's  meningitis  policy  and  actual  practise  as  regarding 
timing of lumbar puncture.  You may wish to know that all actions and recommendations were 
undertaken in line with the target dates, and all by November 2021. 

I ·am  also aware of the Trust's response to your report, which has considered the transfer of 
patients and  improvements of transfer documents,  the developments of standard operating  . 
procedures,  including  lumbar puncture,  and patient fall  and improvements to education and 
assessment with monitoring of compliance. 

More  generally,  you  may  wish  to  know  that  the  National  Institute  for  Health  and  Care 
Excellence  (NICE)  guidance  on  delirium  (CG103)4,  which  covers  diagnosing  and  treating 
delirium  in  people  aged  18  and  over  in  hospital,  as  well  as  identifying  people  at  risk  of 
developing delirium and preventing onset, would be applicable in this case. Moreover, NICE's 
guideline  on  meningitis  (bacterial)  and  meningococcal  septicaemia  in  under  16  (CG102)5, 
includes a section on performing lumbar puncture and interpreting cerebrospinal parameters 
for suspected bacterial meningitis, however NICE have not published a guideline on meningitis 
in adults. NICE is currently in the process of updating CG102 and have extended the scope 
to include people aged 16 and over. 

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

Yours sincerely, 

WILL QUINCE MP 
MINISTER OF STATE 

4 htteia://www.nice.org.uk/guigance/cg103 
5  https://www .nice.orq.uk/guidance/cq102

The Business Centre, Bank Top Farm, Blackhill Road, Otley, LS21 1PY 

E: enquiries@onemedicalgroup.co.uk 
onemedicalgroup.co.uk 

Mr Kevin McLoughlin 
Senior Coroner for West Yorkshire (East) 
HM Coroner's Court 
71 Northgate 
Wakefield 
WF1 3BS 

4 February 2022 

Dear Mr McLoughlin 

I am writing to you in response to your Regulation 28 report dated 3 December 2021, following the 
inquest into the death of Alexander Theodossiadis, which you conducted over the course of two 
days on 17 and 30 November 2021. 

First, and on behalf of all the staff at One Medical Group, I would like to express my deepest 
condolences to Alex's family. It was clear from all that was said at the inquest that Alex was a kind, 
creative individual with a bright future in the music industry ahead of him, and that he was well-
loved by many friends and family. We were all deeply saddened by his tragic death. 

Your report raises two matters that cause you concern and I shall take each in turn. 

(1) The Inquest heard evidence that when Mr Theodossiadis sought an appointment with a GP he 
was only able to get one in three weeks’ time. He did not venture any details of his symptoms. 
Nor, however, did the GP's receptionist probe to obtain any information which would help to 
assess the urgency of the situation or the priority to be given to his request. Within six days of this 
telephone call, Mr Theodossiadis was irretrievably overwhelmed with a meningitis infection. 

One Medical Group appreciates that it can be difficult for individuals to navigate health services to 
secure appropriate assistance, particularly in the case of a usually young and fit man who hasn't had 
previous contact with health services, and who is new to a geographical area. One Medical Group 
notes that you heard evidence that Alex had not previously had cause to interact with health 
services as an adult, and that when he registered with the GP practice on 16 January 2020 he had 
likely not been registered with a GP for some years before then. 

You were provided with a transcript of the telephone call with the GP receptionist on Monday 20 
January 2020 and heard evidence that Alex was advised that urgent appointments were made 
available at 08:00 each morning if required. Alex was therefore provided with appropriate advice in 
order to secure an urgent appointment should he have felt this was necessary. You found that there 
was no reliable evidence that Alex made any further efforts to secure an appointment with a GP 
after this time until he attended the Walk in Centre at 8am on Friday 24 January 2020. 

You heard evidence from 
listened to the recording of the call between Alex and the GP receptionist and that it was a "very 

, Head of Patient Safety and Quality, that she had 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 The Business Centre, Bank Top Farm, Blackhill Road, Otley, LS21 1PY 

E: enquiries@onemedicalgroup.co.uk 
onemedicalgroup.co.uk 

friendly" conversation in which Alex did not convey any urgency about the need for an appointment. 
This is consistent with your finding that, at the point Alex spoke to the GP receptionist, all involved 
(including Alex) felt he was suffering from flu like symptoms and did not consider it necessary to 
press the GP for an urgent appointment or to take him elsewhere to be cared for. On the balance of 
probabilities, therefore had the receptionist probed to obtain further information she would likely 
have concluded that Alex did not require an urgent appointment. 

You heard evidence from various medical practitioners that meningitis can appear very swiftly; 
"within hours" and you accepted that, on the balance of probabilities, Alex was not displaying any 
relevant meningitis symptoms other than a headache when he was reviewed by ANP 
at 8am on Friday 24 January 2021. It is therefore unlikely that Alex was suffering any red flag 
symptoms four days earlier, on 20 January 2021, when he spoke to the GP receptionist. It is likely 
therefore that further probing by the GP receptionist would not have resulted in Alex reporting 
symptoms that would have necessitated an urgent appointment. 

When One Medical Group heard of Alex's death, it investigated Alex's contacts with the service and 
immediately recognised that its GP receptionist should have asked for more information regarding 
the need for the appointment in accordance with One Medical Group's protocol.  One Medical 
Group apologised to Alex's family that this did not happen.  

The receptionist was no longer employed by One Medical Group and so we were unable to ascertain 
why she failed to probe on this occasion. She was trained to do so (please see below) and the 
expectation of the organisation was that she would question every patient regarding their need for 
an appointment. We are regretfully unable to say why this did not happen on this occasion. 

One Medical Group takes its learning obligations extremely seriously and you heard evidence from 

 that, since Alex's death, refresher red flag training has been undertaken with all GP 
receptionists and non-clinical staff. In addition, an audit of telephone calls to the GP Practice was 
undertaken from September – November 2021. This audit found that all calls were handled in a 
friendly and professional manner, and reception staff asked appropriate questions to ascertain the 
urgency of the appointment i.e. appropriate probing occurred. You also heard evidence from 

 that in mid-2020 more receptionists were employed by the GP practice in order to cope 

with pandemic-related additional demand and the intention is for these employees to remain in 
their role post-pandemic. 

(2) GP receptionists must strike a difficult balance between respecting medical confidence and 
obtaining sufficient information to enable a judgement to be made in relation to access to medical 
help. In the case of fast-moving medical conditions such as meningitis afflicting otherwise healthy 
young people the Inquest heard concerns that refresher training was regularly required but may 
not be provided with sufficient frequency to maintain vigilance at this important interface 
between patients and clinicians. 

OneMedical Group has no recollection of any concerns being raised at the Inquest regarding the 
frequency with which refresher training (either specifically for sepsis and meningitis, or training in 
general) was provided to non-clinical staff. Had this issue been raised, 
able to provide additional evidence. In any event, we are able to respond as follows: 

 would have been 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 The Business Centre, Bank Top Farm, Blackhill Road, Otley, LS21 1PY 

E: enquiries@onemedicalgroup.co.uk 
onemedicalgroup.co.uk 

No regulator or advisory body provides guidance on the content or frequency of mandatory training 
for GP receptionists or non-clinical staff (or indeed for any member of a GP Practice administrative 
team). As noted by the CQC: "ultimately, the practice is responsible for determining what mandatory 
and additional training staff need and how this is delivered".1 

One Medical Group is acutely aware of the importance of appropriate training and has implemented 
a rigorous training programme. As explained in the letter dated 13 August 2020 from 

, Director of Professions at One Medical Group (pages A.95 – A.98 of the inquest 

bundle), NHS England identified in the 2016 'GP Forward View' Guidance2 that training for reception 
and non-clinical staff was a "high impact" action. As a result of this 2016 Guidance, One Medical 
Group developed and implemented bespoke training for its reception and non-clinical staff. 

Staff training is a key line of enquiry considered by the CQC during any inspection and it is of note 
that during their most recent inspection of the GP Practice (15 February 2019) the CQC found3: 

1.  "All staff received up-to-date safeguarding and safety training appropriate to their role. They 

knew how to identify and report concerns." 

2.  "There was an effective induction system for temporary staff tailored to their role. This 

included a mandatory three-day corporate induction prior to starting with the organisation. 
The corporate induction covered all mandatory training including basic life support." 

3.  "Staff were suitably trained in emergency procedures." 

4.  "The practice understood the learning needs of staff and provided protected time and 
training to meet them. Up-to-date records of skills, qualifications and training were 
maintained. Staff were encouraged and given opportunities to develop. At the time of our 
inspection a number of staff were being supported by the practice to complete additional 
training." 

5.  "The practice provided staff with ongoing support. There was an induction programme for 

new staff. This included a mandatory three-day corporate induction prior to starting with the 
organisation. The corporate induction covered all mandatory training including basic life 
support." 

6.  "The practice had plans in place and had trained staff for major incidents." 

1 https://www.cqc.org.uk/guidance-providers/gps/gp-mythbuster-70-mandatory-training-
considerations-general-practice 
2 https://www.england.nhs.uk/wp-content/uploads/2016/04/gpfv.pdf 
3 https://api.cqc.org.uk/public/v1/reports/5b8d65d6-1ab9-495a-a0ae-
42378bc9be86?20210116092739 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 The Business Centre, Bank Top Farm, Blackhill Road, Otley, LS21 1PY 

E: enquiries@onemedicalgroup.co.uk 
onemedicalgroup.co.uk 

The CQC report also contained a quote from a patient commenting that "The reception staff are 
great and welcoming and very approachable". 

You heard evidence from 
 that GP receptionists and non-clinical staff have "red flag" 
training whereby they must demonstrate knowledge of various "red flag" symptoms necessitating 
further follow up. 
 provided the example that if a patient mentioned chest pain then a 
receptionist is trained to get immediate advice from a clinician and then advise the patient to call 
999 or to attend the GP practice urgently (depending on the clinician's preliminary view). You also 
heard evidence that GP receptionists and non-clinical staff are trained to identify vulnerable patients 
who may struggle to convey their symptoms and 
with dementia requiring additional assistance. 

 provided the example of a patient 

 told you that the training provided is interactive and contains lots of scenarios. In the 

, it was explained that the training includes group 

letter dated 13 August 2020 from 
discussions, case-based reviews, PowerPoint presentations and short educational video clips. Staff 
understanding is reviewed through an assessment following the training session. If a staff member 
failed to show sufficient understanding, they would be required to re-attend the training. You were 
provided with a copy of the training presentation and assessment sheets for both red flags and 
sepsis recognition for non-clinical staff. The final slide of the training presentation (at page A.111 of 
the bundle) is as follows: 

"- What should you do if you suspect a patient has sepsis? 

YOU MUST BOOK THE PATIENT TO BE SEEN BY A CLINICAN AS SOON AS POSSIBLE (TODAY!!) 
AND INFORM THE CLINICAL TEAM IMMEDIATELY 

HOWEVER, IF THE PATIENT REPORTS ANY OF THE FOLLOWING – YOU MUST CALL AN 
AMBULANCE… 

- CHEST PAIN / IRREGULAR HEART BEAT 

- DIFFICULTY BREATHING 

- SOMEONE TELLS YOU THE PATIENT IS CONFUSED (AND ISN'T USUALLY) OR IS DIFFICULT TO 
WAKE 

Always speak to a clinician if you are unsure……!" 

It is therefore apparent that, during the training, significant emphasis is placed on the relevant red 
flag symptoms for meningitis and other conditions and that non-clinical staff are required to err on 
the side of caution if they have any concerns. One Medical Group considers the training is 
comprehensive and thorough and notes that no concerns have been raised about the content of the 
training provided. 

You heard evidence that the training for non-clinical staff is refreshed on an annual basis and One 
Medical Group strongly disagrees with your suggestion in the PFD Report that refresher training was 
not provided with sufficient frequency to maintain vigilance. As stated above, there is no CQC or any 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 The Business Centre, Bank Top Farm, Blackhill Road, Otley, LS21 1PY 

E: enquiries@onemedicalgroup.co.uk 
onemedicalgroup.co.uk 

other guidance on the frequency of training for GP receptionists and non-clinical staff, however it is 
of note that Practice Index, the UK's leading provider of support and services to GP Practice 
Managers, recommends that sepsis training is undertaken annually for all staff4. Indeed, of the 18 
different training areas identified by this organisation for all GP members of staff, no one area is 
recommended to be repeated more frequently than annually. One Medical Group therefore has no 
doubt that the frequency of training of non-clinical staff is appropriate and in line with GP practices 
across the country. 

The receptionist who took Alex's call had received sepsis training six months before taking Alex's call. 
She had demonstrated a high level of understanding of the training and increased frequency of 
training is unlikely to have resulted in the receptionist having had any more recent training prior to 
the relevant date. One Medical Group believes that the receptionist's failure to probe on this 
occasion was likely an isolated circumstance and, as set out above, audits have shown that this is not 
a recurring issue. The annual training provided to reception staff emphasises the need to elicit 
information from all patients in order to establish the urgency of their need for an appointment. 

I would like to take the opportunity to assure you, and Alex's family, that One Medical Group seeks 
to learn from all untoward incidents and absolutely recognises that Alex's death was the most 
serious type of such incidents. As outlined in the evidence of 
 during the inquest, One 
Medical Group has already taken learning from Alex's extremely sad death and will continue to do 
so. Again, I send my deepest condolences to Alex's family. 

Yours sincerely 

CEO, OneMedical Group 

4 https://practiceindex.co.uk/gp/blog/mandatory-training-requirements-what-when-and-who/

RC Royal College of
G P General Practitioners
J

mC
Honorary Secretary of Council

Mr Kevin McLoughlin
Senior Coroner for the Coroner area of West Yorkshire

q
26 January 2022

Dear Mr McLoughlin,
Regulation 28 Report to Prevent Future Deaths - touching on the death of Alexander George
Theodossiadis

Thank you for your letter of 3 December 2021. | am responding on behalf of the Royal College
of General Practitioners as Honorary Secretary to Council. Firstly, can | convey our condolences
to the family and friends of Alexander Theodossiadis. | was saddened to read of Alexander's
passing.

The Royal College of General Practitioners (RCGP) is the largest membership organisation in the
United Kingdom solely for GPs. It aims to encourage and maintain the highest standards of
general medical practice and to act as the ‘voice’ of GPs on issues concerned with education;
training; research; and clinical standards. Founded in 1952, the RCGP has just over 54,000
promoting general practice as a discipline.

You have asked the RCGP about GP reception staff and their training for the role. In particular
whether receptionists could ask more questions of patients who do not request urgent
appointments. The report details that the events leading to the inquest took place before the
Coronavirus Pandemic. The custom and practice at the time was to offer and book the first
available appointment without questioning of the patient. If the patient wanted a more urgent
to the GP and could ask for different priority if requested by the patient.

Royal College of General Practitioners

30 Euston Square, London, NW1 2FB
Tek 020 3188 7400 | info@rcgp.org.uk | rcgp.org.uk
Patron: HRH The Duke of Edinburgh (1972-2021) | Registered Charity Number 223106

system came under progressive strain urgent patients were prioritised. As a consequence, the
length of time to a non-urgent appointment increased. Patients could book an appointment with
a GP without explanation if they wished. When that was a choice of urgent today or unrestricted
in three or four days it was acceptable. No one in the system wanted there to be a three week
might have been provided but the narrative suggests that the patient felt he had a viral illness at
that time.

Since the pandemic the custom and practice has completely changed. Detailed information is
requested from patients when they request appointments. The information given is reviewed
and frequently a telephone call arranged with a clinician to consult with the patient. There are
also different options to reach the practice now. Direct attendance without a booked face to
face appointment is discouraged but telephone and email are more available. After an initial dip
in first lockdown the number of requests for consultations has increased. There are figures from
NHS Digital (Experimental Figures and therefore caution is advised) that show a 10% increase in
appointments between October 2019 and October 2021. Patients now receive clinician triage or
an appointment as a way of dealing efficiently with the increased numbers of appointment
including a GP is no longer available. When patients are first consulted by telephone those that
need them are brought down for face-to-face consultations.

The system has moved from requests to receptionists to clinicians as initial point of consultation
and triage. This is not the same as the suggested option of receptionists asking for information
but should provide a higher level of clinical safety and service. There is no formal requirement for
practices to consult in this way and they could still offer open face to face appointments, but
most do not. The telephone clinician appointments are usually more rapidly available. This is in
line with your request for more information to be gathered from patients when booking
appointments.

| trust that this reply is helpful and if you have any questions, please do not hesitate to contact
me.

Yours sincerely,
WANS.
>,

Honorary Secretary
Royal College of General Practitioners

7 February 2022 

Your Ref: 

Mr Kevin McLoughlin 
Senior Coroner 
West Yorkshire (Eastern) 
Coroner’s Office and Court 
71 Northgate 
Wakefield 
WF1 3BS 

Dear Mr McLoughlin 

Chief Medical Officer 
Trust Headquarters 
St James’s University Hospital 
Beckett Street 
Leeds 
LS9 7TF 

www.leedsth.nhs.uk 

INQUEST TOUCHING THE DEATH OF ALEXANDER THEODOSSIADIS (Deceased) 

I  refer  to  your  correspondence  of  3rd  December 2021,  regarding  the  inquest  touching  the 
death  of  Mr  Alexander  Theodossadis  and  the  Regulation  28  Report  to  Prevent  Future 
Deaths in respect of this case. 

I  can  confirm  that  the  contents  of  your  Regulation  28  Report  have  been  shared  with  the 
relevant staff to enable us to provide you with a comprehensive response.   

In your report you highlight that your matters of concern were as follows: 

(1) Evidence  was  taken  at  the  Inquest  which  indicated  Mr  Theodossiadis  was  moved
from  one  hospital  within  the  Trust  to  another,  close  to  midnight  on  25th  January
2020.  Despite  being  severely  unwell  with  bacterial  meningitis  and  a  confused  state
he was not accompanied by a nurse escort, nor was any written handover instruction
or  briefing  note  provided  for  the  nurses  receiving  him,  in  breach  of  the  prevailing
Trust handover guidance.

(2) Mr Theodossiadis remained in A&E for some 10 hours in total, despite the nature of
his condition. Concern was expressed at the Inquest in relation to first, the absence
of  clear  instructions  regarding  the  need  for  a  lumbar  puncture  within  four  hours  of
admission;  secondly,  a  clear  pathway  to  an  appropriate  treatment  location;  thirdly,
any directions specifying the timetable in which action was required in response to a
life-threatening condition.

 
 
 
 7 February 2022 

Your Ref: 

(3) The inquest heard evidence that practice differs nationally on the need for a lumbar 
puncture  in  cases  of  meningitis.  The  absence  of  clear  leadership  on  this  issue 
nationally  does  not  assist  clinicians  who  may  encounter  this  relatively  rare,  but 
serious condition.  

(4) Despite  spending  10  hours  in  A&E  and  displaying  increasing  signs  of  confusion  he 

was seen to be trying to get of his hospital bed which created a risk of falls, no  

(5) assessment of the falls risk was carried out. In consequence the receiving ward J27 
at St James’s University Hospital, Leeds were not forewarned of the risk of falls. He 
fell  from  his hospital bed within approximately 10  minutes of  being  placed  in  a  side 
room on his own. 

We have considered the contents of your report very carefully and our response is set out 
below. 

(a) Transfer of patients 

The  Trust  accepts  that  Mr  Theodossiadis  did  not  have  a  nurse  escort  when  he  was 
transferred  to  St  James’s  Hospital.  This  would  have  facilitated  a  handover  of  care  to  the 
Ward J27 nursing team, including the fact that the patient was at risk of falls.  

Given the large volumes of patients within both Emergency Departments across the city, it 
is  sometimes  not  possible  or  practicable  for  a  nurse  to  personally  escort  patients  for  a 
cross-city transfer. To do so would deplete the department of an experienced nurse for over 
an  hour,  with  the  potential  to  compromise  care  of  other  patients  waiting  for  treatment. 
Instead, patients will be handed over to the care of the Yorkshire Ambulance Service who 
will  facilitate  safe  transfer.  For  transfers  within  the  same  hospital,  a  now  improving  staff 
position means that, wherever possible, the patient will be accompanied to the new ward or 
clinical area by a member of the ED staff so that a direct handover can be facilitated. 

For cross-city transfers we must ensure a robust handover of care between nursing staff in 
the ED and on the receiving ward. This may take the form of a telephone conversation but 
this  should  always  be  accompanied  by  a  written  handover  document.  Currently  in  the 
Emergency Department this takes the form of a written document that is then scanned into 
the electronic patient record (PPM+). The Trust is currently trialling a stand-alone electronic 
transfer document and it is anticipated that this will be rolled out to all areas of the Trust in 
due course.  

The  Trust  is  working  towards  100%  compliance  with  use  of  the  transfer  document  and  a 
rolling audit programme has been taking place for over 12 months to monitor progress. The 
latest audit figures are encouraging but the Trust recognises that this improvement must be 
sustained  and  therefore  the  process  of  regular  audit  will  continue.  In  addition,  we  are 

 
 
 
 
 
 
 
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Your Ref: 

seeking an understanding with YAS that they will not accept patients for transfer without a 
handover document which clearly records the patient’s falls risk.  

(b) Lumbar puncture 

The  Trust  notes  the  Coroner’s  concerns  regarding  the  need  for  lumbar  puncture.  It  is 
recognised  that  whilst  there  is  national  guidance  on  the  indications  and  timing  of  lumbar 
puncture, practice is varied throughout the country. This may be due to a number of factors: 

1.  Lumbar  puncture  is  a  diagnostic  test  rather  than  a  treatment.  As  in  the  case  of  Mr 
Theodossiadis,  antibiotics  were  administered  shortly  after  he  attended 
the 
Emergency  Department  in  line  with  Trust  and  national  guidance.  In  other  words, 
treatment  was  commenced  as  soon  as  the  team  were  suspicious  of  a  serious 
pathology such as sepsis or meningitis. Had a lumbar puncture been carried out first 
and the results awaited, his life-saving treatment would have been delayed. 

2.  In  this  context,  the  main  purposes  of  the  lumbar  puncture  are  to  confirm  the 
diagnosis of meningitis, to differentiate between bacterial and viral meningitis, and to 
guide  antibiotic  therapy  later  in  treatment.  Lumbar  puncture  can  be  a  painful 
procedure  and  is  difficult  to  carry  out  if  the  patient  is  confused  or  restless.  It  is  a 
sterile procedure which requires an experienced practitioner to carry it out safely. In a 
busy  emergency  department  this  can  be  a  logistical  challenge.  If  the  procedure  is 
delayed, its potential benefits begin to diminish as treatment has already commenced 
and the chances of culturing a specific organism are reduced.  

3.  Lumbar puncture is not without risk, with serious complications well recognised. It is 
contraindicated  where  there  is  evidence  of  coagulopathy  or  raised  intracranial 
pressure.  In  practice  this  means  that  an  unwell  patient  with  possible  meningitis  will 
require blood tests and a brain CT scan reported by a radiologist prior to the lumbar 
puncture being carried out. These require some time to be performed and the results 
then  processed,  which  again  in  the  context  of  a  busy  emergency  department  will 
lessen the value of the test being carried out at a later point. 

However, the Trust does recognise the potential value of an early lumbar puncture (LP) and 
is  endeavouring  to  provide  this  diagnostic  test  where  possible.  Specifically,  a  lumbar 
puncture  may  allow  antibiotic  therapy  to  be  rationalised,  with  broad  spectrum  treatment 
being replaced with more specific antibiotics. As such the Trust has developed a standard 
operating procedure (SOP) with the aim of carrying out a lumbar puncture within one hour 
wherever possible. At St James’s University Hospital during daytime hours (8am-8pm), the 
patient  will  be  transferred  to  the  Same  Day  Emergency  Care  (SDEC)  unit  adjacent  to  the 
Emergency Department where the LP will be carried out by a medical registrar or Advanced 
Practitioner. SDEC is a more suitable environment for the LP to be carried out as it is a less 
congested  and  more  private  area  where  sterility  can  be  more  easily  maintained  for  the 
procedure  to  be  carried  out  safely.    The  SOP  should  mean  that  patients  with  suspected 

 
 
 
 
 
 
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Your Ref: 

meningitis  spend  much  less  time  in  the  Emergency  Department  and  can  have  the  lumbar 
puncture  performed  by  an  experienced  practitioner  in  a  timely  fashion.  It  is  hoped  that  in 
due course the service will be available in the St James’s SDEC 24 hours per day. Further 
consideration is being given to how a similar arrangement could be provided at the LGI site. 

(c) Patient falls 

It is recognised that the Emergency Department is a high risk area for patient falls as many 
attenders  are  frail  or  have  pathology  that  increases  their  risk.  This  of  course  includes 
patients  such  as  Mr  Theodossiadis  who  are  confused  because  of  infection  or  intracranial 
pathology. 

The  Trust  would  like  to  reassure  the  Coroner  that  it  takes  the  risks  of  falls  within  the 
Emergency  Department  very  seriously.  All  patients  within  the  department  should  have  a 
falls  assessment  recorded.  As  in  the  case  of  the  handover  document,  compliance  is 
continuously  audited.  The  latest  audit  figures  demonstrate  excellent  compliance  with  the 
tool,  but  the  department  recognises  that  this  must  be  sustained  to  prevent  future  harm  to 
patients. 

I can confirm that Mr Theodossiadis did have a falls risk assessment completed at 13.14 by 
the assessment nurse which was entered on to the ED electronic patient record Symphony. 
He was not deemed to be a falls risk. However when he later became more confused, his 
assessment should have been repeated. The senior members of the ED nursing team fully 
recognise the need for repeated assessments when the patient’s condition changes and are 
working hard to ensure that this practice is embedded within the department. 

 We are monitoring and auditing compliance regarding safety and dignity checks within the 
department  on  a  daily  basis.  This  includes  identifying,  risk  assessing  and  monitoring 
concerns for patients who are at risk, including falls.  

We have improved our education and understanding of patient risk across the department 
regarding  falls  and  the  importance  of  rapid  and  correct  assessment  of  patients  on  arrival, 
and the on-going assessment during their stay in ED. The risk of patient falls is continuously 
highlighted  within  the  Emergency  Department.  Staff  have  regular  safety  huddles  where 
vulnerable  patients  are  discussed.  In  addition,  dedicated  ‘falls  awareness’  boards  have 
been  placed  throughout  the  departments  to  raise  staff  awareness  and  promote  best 
practice.  Practical  initiatives  that  have  been  implemented  include  the  provision  of  yellow 
socks for patients at risk of falls to provide a clear visual cue for staff. In addition, we now 
request additional Clinical Support Worker bank shifts to meet enhanced care needs of our 
vulnerable patients.  

In  the  event  that  a  fall  incident  does  occur,  all  falls  are  reported  on  the  Trust’s  incident 
reporting  system  Datix  and  a  root  cause  analysis  (RCA)  is  carried  out  for  each  case  to 
identify learning points. The Head of Nursing for the Emergency Department reports directly 

 
 
 
 
 
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Your Ref: 

to  the  Executive  Team  including  the  Chief  Medical  Officer  and  Chief  Nurse  at  the Weekly 
Quality Meeting for assurance. She reports on a number of key metrics including falls within 
the department.  

Thank  you  for  bringing  these  matters  to  my  attention.  I  do  hope  that  this  response  has 
assured  you  that  the  Trust  has  given  careful  consideration  to  the  matters  of  concern  you 
have raised. 

If I can be of any further assistance please do not hesitate to contact me. 

Kind regards 

Yours sincerely 

Dr 
Chief Medical Officer and Deputy Chief Executive 
Leeds Teaching Hospitals NHS Trust