Alphonso Shearer

Greater Manchester  Health and Social Care Partnership 
4th Floor 
3 Piccadilly Place 
London  Road 
Manchester  M1 3BN 

E: 

Date: 22 June 2022 

Ms A Mutch 
HM Senior  Coroner  
Coroner’s  Court   
1 Mount Tabor   Street   
Stockport   
SK1 3AG  

Dear Ms Mutch,  

Re:  Regulation  28  Report  to  Prevent  Future  Deaths  –  Alphonso  Alexander 
Shearer 17/8/21 

Thank  you  for sharing  the  Regulation  28  Report  dated  28/4/22  concerning  the  sad 
death  of Alphonso  Alexander  Shearer  on  17/8/21.  Firstly,  I would  like to  express  my 
deep  condolences  to Alphonso  Alexander  Shearer’s  family.  

The  inquest  concluded  that  Alphonso’s  death  was  a  result  of  1a  Urosepsis  on  a 
background  of  catheterisation;  1b  Chronic  Kidney  Disease; 
II  Oesophageal 
carcinoma, hypertension. 

The Regulation  28 Report  raises  concerns that  there is  a risk future deaths  will occur 
unless  action is taken. 

This letter addresses  the issues  that fall within the remit of Greater Manchester Health 
and Social Care Partnership  (GMHSCP) and how we can share  the learning  from this 
case. 

This  matter has  been reviewed by a Senior  Primary Care Manager  for GMHSCP with 
focus on the following points,  raised  by the Coroner: 

1.  The  inquest  heard  that  Mr  Shearer  was  frail  and  vulnerable  with  very  poor 
swallow.  When prescribing  the clinicians  did not recognise  or have a system to 
flag up  the  need  for liquid  antibiotics  rather  than  tablet  antibiotics.  This  led  to 
him  not  being  able  to  commence antibiotics  on  the  day  he  was  identified  as 
needing  them.  The  inquest  heard  that  it  is  important  that  in  the  community 

 
 
 
 
    
 
 
 
 
 
 
 
 
 
 
 particularly  for  the  vulnerable  there  is  a  system  for  recognising  what  form of 
antibiotics  are most appropriate  to prescribe  to avoid delay.  

2.  The inquest  heard that the ASK MY GP system had been challenging  for those 
involved  with Mr Shearer and  had made communication  harder.  The evidence 
identified  that  this was a particular  issue  for more vulnerable  patients  and their 
families.  

3.  The  inquest  heard  that  he  had  not  been  seen  face to  face by  a GP  and  that 
meant  that  the full  extent of his  deterioration  was  not  recognised  until  he was 
seen  by a paramedic from the practice who called an ambulance.   

Response  to the points raised by the Coroner: 

In  Greater  Manchester  we  strive  to  deliver  the  safest  care  for our  patients,  service 
users  and  families,  and  design  the safest  systems  for our staff, and  in  doing  this  it is 
vital we are able  to adapt to the evolving  nature of the health  and  care system. Given 
the prominence of digital  technologies,  and their essential  role in clinical care delivery, 
it is crucial that the patient  record is maintained  to support  safety and reduce errors.  It 
is  also  essential  that  digital  innovation  is  delivered  safely  and  does  not  lead  to 
unintended  harms. 

The  potential  for digital  technologies  to enhance  safety in areas  such as  prescribing, 
record  keeping,  and  data  driven  health  and  care  is  widely  evidenced.  However,  we 
recognise  that  digital  technologies  without  the  appropriate  mechanisms  to  indicate 
safety concerns ‘’ can have the potential  to harm patients.   

The  new  National  Patient  Safety Strategy,  focusing  on  digital  technologies,  and  the 
national  commitments  and  timescales  it  contains,  will  complement,  and  support  the 
work currently underway in Greater Manchester as we collaborate  across primary care 
and hospital  services to reduce avoidable  harm to patients.   

It is our commitment to: 

• 
• 

Improve the safety of digital  technologies  in health  and care, now and in the future. 
Identify, and  promote  the use  of, digital  technologies  as  solutions  to  patient  safety 
challenges. 

•  Develop new digital  clinical safety training  materials  and expand access to training 

across the health  and  care workforce. 

•  Create a centralised  source of digital  clinical safety information, including  optimised 

standards,  guidelines,  and best  practice blueprints. 

With regard to the specific matter of GP practices having  a system to flag the need  for 
liquid  antibiotics  rather  than  tablet  antibiotics.  Led  by  the  regional  chief  pharmacist, 
NHS  England  has  produced  ‘An  Interactive  Guide  To:  Principles  of  Safe  Medicine 
Administration  in a Care Home Setting’ to be used across the region,  and this includes 
principles  for safeguarding  individuals.  These  principles  are also  applicable  for those 
living in their  own home.  

We  are  aware  that  current  workload  pressures  in  general  practice  continue  to  be 
challenging,  as practices are still  coping with the additional  demand and constraints  of 
the pandemic.  

General practice continues to experience the release of pent-up demand, accumulated 
during  the  pandemic  when  people  were  less  likely  to  consult  their  practice  or  seek 

 
 
 
 
 specialist  care. Many practices are still  catching up on the backlog of care for patients 
who have ongoing  conditions. 

However,  general  practice  remains  resilient  and 
last  year,  provided  more 
appointments  nationally  for patients  than in the equivalent  period before the pandemic. 
Although  it  may  not  have  appeared  so  in  surgery  waiting  rooms,  given  social 
distancing  requirements  and  the  growth  in telephone  and  online  consultations,  most 
general  practice teams across Greater Manchester  have never been  busier. 

The majority of practices have been able  to adapt  and innovate  during  the pandemic, 
to maintain  and improve access, including  the use of remote appointments.   

At the  same  time,  we know that  patients’  access  primary care  has  also  not  been  as 
good  as  it should  be. Some patients  have experienced  unacceptably  poor  access  to 
general practice, including difficulty in contacting practices and seeing a GP, for a face-
to-face appointment  in particular. 

We  acknowledge  that  those  with  the  greatest  health  needs  are  sometimes  also  the 
most  at  risk  of  being  left  behind  by the  ability  to  access,  manage  and  contribute  to 
digital  tools,  information  and  services.  We  continue  to  work with  our  digital  and  GP 
service  providers  to  ensure  these  technologies  work  for  everyone,  from  the  most 
digitally  literate  to  the  most  technology  averse,  and  that  they  reflect  the  needs  of 
people  trying to stay healthy,  as well as those  with complex conditions. 

Actions  taken,  or  being  taken,  to  prevent  reoccurrence  across  Greater 
Manchester. 

• 

In October 2021, NHS England  set out a plan for improving access for patients  and 
supporting  general  practice.  This  sets  out  how  we  will  increase  and  optimise 
capacity,  address  variation,  encourage  good  practice,  and  improve  access, 
including  face-to-face appointments  with GPs.  

•  As  part  of this  plan,  general  practice  teams  across  Greater  Manchester  are  now 
reviewing the balance  for patients  between remote and face-to-face consultations, 
as  part  of ongoing  reflections  on  professional  practice and  surgery  management 
arrangements. 

•  Greater  Manchester  integrated  care  system  has  completed  an  action  plan  with 
further steps  to support  improved access and address  healthcare  inequalities.  The 
plan  includes  how  each  of  our  10  local  systems  will  tackle  variation  in  general 
practice, which is our utmost priority. This  will continue  to be progressed  following 
the establishment  of NHS Greater Manchester  Integrated  Care and the closure  of 
local clinical commissioning  groups  on 1 July:  

(i) 

(ii) 

ensure  all  practices  achieve  at  least  pre-pandemic  activity  levels  for  the 
equivalent  period (excluding  COVID-19 vaccinations)   
increase  overall  appointment  volumes  in  general  practice  and  ensure 
appointment  levels  reflect  the  full  deployment  of  additional  roles  in  general 
practice  
increase  the proportion  of face-to-face appointments  with GPs  

(iii) 
(iv)  minimise  111  calls  in-hours  and  avoidable  A&E  attendance 

that  could 

otherwise  be seen  in general  practice, and  

 
 
 
 (v) 

support  all  practices,  to  sign  up  to  and  make  full  use  of  general  practice 
referrals to the community pharmacy consultation  service for minor illnesses  to 
divert demand and improve patient  experience 

•  Learning  to  be  presented/shared  with  the  Greater  Manchester  System  Quality 
Group.   This  meeting  is  attended  by  commissioners,  including  commissioners  of 
specialist  services,  regulators,  Healthwatch,  local  authority  representatives  and 
NICE. 

Alongside  this  we are  also  working  with  the  Care Quality  Commission  (CQC), which 
will  work  with  NHS  England  to  support  systems  in  this  process  and  to  make  the 
required  improvements  across  those  practices  which  are  not  meeting  reasonable 
needs  of patients.  The  CQC is  rapidly  developing  an  inspection  methodology  with  a 
particular  focus on access to GP services.  

To  share  the  learning  from  this  case  we  will  also  reiterate  the  importance  of 
standardised  and  consistent  recording  of  medication  requirements  on  the  patient 
record,  and  ensuring  that  protocols  for prescribing,  particularly  when  the  patient  has 
not been  seen face-to-face by the practice, include a safety netting  element. 

GMHSCP  is  committed  to  improving  outcomes  for  the  population  of  Greater 
Manchester.  Key learning  points  and  recommendations  will  be  monitored  to  ensure 
they are embedded  within  practice. 

I  hope  this  response  provides  the  relevant  assurances  you  require.  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 

Interim Director of Nursing,   
Greater Manchester  Health and Social Care Partnership

Chester Road Surgery 
864-866 Chester Road 
Stretford, Manchester 
M32 0PA 

Seymour Grove Health Centre 
70 Seymour Grove, Old Trafford 

Manchester, M16 0LW  N 

NORTH TRAFFORDGROUP PRACTICE 

Partners 

p 

Business Manager

Practice Email:

Alison Mutch 

HM Senior Coroner 
Coroner's Court 
1 Mount Tabor Street 
Stockport 
SKl 3AG 

17-6-2022 

Dear Ms Mutch, 

Re: Regulation 28 Report into the death of Alphonso Shearer 

We are grateful that you  have  shared  with  us  the findings  from  your inquest and  the  matters  of 
concern that you have raised. 

We would like to express our sincere condolences to the family for their loss and express our apologies 
for any distress caused to them during this difficult t ime. 

We  have considered  this matter and the issues raised  in the Prevention of Future Deaths Report in 
great depth. Where relevant, we have made changes to our systems and processes within the North 
Trafford Group Practice in order to address the matters of concern raised. We have  also  reviewed, 
reinforced  and  w ill  continue  to educate  staff about  existing  safety  practices  where this  has  been 
considered relevant to addressing the concerns. 

Our responses to each of the matters or concern are provided as follows. 

Concern 1: 

The inquest heard that Mr Shearer was frail and vulnerable with very poor swallow. When prescribing 
the clinicians did not recognise or have a system to flag up the need for liquid antibiotics rather than 
tablet antibiotics. This led to him not being able to commence antibiotics on the day he was identified 
as needing them.  The  inquest heard that it  is important that in  the community particularly for the 
vulnerable there is a system for recognising whatform of antibiotics are most appropriate to prescribe 
to avoid delay. 

Page 1 of4 

 
 
 Response to Concern 1 

Our clinical record system is called EMISWeb which is a system  used  by all  practices in Trafford and 
many others across the UK. We record all patient appointments and consultations into this system. 

The system has the ability to add a pop-up warning alert when loading the patient record, and when 
changing between different views such as  looking at the problem list or prescribing a medication. 

The  Practice  has  now adopted the policy of adding  alerts to all  patients who  could  have  difficulty 
swallowing medication. 

As part of implementing this system, we are currently in the process of identifying patients within our 
practice  who  meet the criteria  to  have  this flag  applied.  We are searching  our records  to identify 
patients who  have  been  coded  with swallowing difficulties,  as  well  as  patients with  indications of 

potential  swallowing  difficulties  such  as  those  already  receiving  liquid  medication,  nutritional 
supplements or feeds. We are aiming over the next 4 weeks to add a flag of 'Difficulty swallowing pills' 
where appropriate for these patients. The system will then allow us to search for patients with this 
code. 

Our medicines management team will add the alerts to the clinical  system as well  as to the screen 
message  on  the  prescribing view for the  patient.  This  will  prompt clinicians  when  reviewing  such 
patients or making changes to medication to make sure they prescribe medication that is suitable for 
the patient such as in soluble or liquid form if necessary. 

In addition to the above system changes, we have also discussed this matter as a learning event within 
the senior team at the practice, and will be disseminating the learning from this. We will also have a 
further discussion in our next clinical meeting so that the clinical staff are aware of the new flagging 
process and how to enter the clinical codes and alerts in the EMISWeb system. 

When a hospital letter comes through indicating any changes in the patient's ability to swallow, our 
workflow  team  will  be  trained  to  enter  the  codes  and  alerts  as  appropriate.  Our  medicines 
management team will be  conducting searches  on a monthly basis to ensure the appropriate alerts 
are in place. We will review this process after the first 3 months. 

If a  patient  finds  they are  unable  to take  a  medication  after  it  is  dispensed,  or the  community 
pharmacist identifies that the patient is  unable to take the medication, existing systems  allow the 

patient or pharmacist to contact the surgery to request an  alternative be delivered. The  Practice is 
open  until 18:30 hours for an  alternative medication to be  issued.  If a patient requests medication 
that has  been  discussed at a previous consultation, a new consultation request is  generated for the 
previous clinician to ensure continuity of care.  However, if not available the request is passed to the 

on-call  doctor who will then speak to the patient having reviewed the previous consultation. After 
18:30  hours the call  is  directed to the NHS111  service  to direct them to our out of hours  medical 
services  provider,  Mastercall,  who  would  consult  with  the  patient  and  send  a  prescription  for 
alternative medication to a pharmacy if required. 

Concern 2. 

The inquest heard that the ASK MY GP system had been challenging for those involved with Mr Shearer 
and had made communication harder. The evidence identified that this was a particular issue for more 
vulnerable patients and their families. 

Page 2 of4 

 Response to Concern 2 

Following the NHS Long Term Plan to improve digital access for patients, a number of different digital 
solutions were considered. In 2019 North Trafford Group Practice, along with many others in Trafford, 
with support from the CCG, decided to use AskMyGP as a digital solution. 

The AskMyGP system was implemented in March 2020. It allows requests that come in from patients 
to be  workflowed in  the practice.  Requests  can  be  submitted in a variety of ways  including online 
directly into the system, via telephone, or in person where a member of staff would enter it into the 
system on behalf of the caller or attending patient. 

All  requests for consultations in AskMyGP  are allocated to a clinician. Depending on the information 
provided,  the  clinician  would  contact  the  patient  by  telephone  or  by  email,  and  if needed  could 
arrange a video consultation, face to face consultation at the surgery, or a home visit if required. 

We have found that approximately 70% percent of our patients use the AskMyGP service themselves. 
One  added  benefit of allowing patients to make  requests online is that it makes it easier for other 
patients who are unable to use the online system to contact the surgery by phone as there is a lower 
volume of calls. 

As  mentioned earlier, the EMISWeb system  allows us  to put alerts  on  patients records to indicate 
when they are more vulnerable or if they struggle to use digital access. In response to the concern, we 
are  in  the  process  of putting  these  alerts  in  the  system  for  relevant  patients.  We  are  hoping to 
complete this process over the next 4 weeks. This will help by alerting our staff that the patient may 
need extra support when requesting a consultation, or have specific requirements for the consultation 
such as  an  interpreter. This process has  been  discussed  at practice meetings and  is  part of our call 
handling protocol. 

We have discussed  patient access  and the use of the AskMyGP  system  at our Patient Participation 
Group  (PPG)  meetings  on  several  occasions.  We  have  received  good  feedback  overall  about the 
system.  However,  we  will  also  discuss  the  learnings  from  this  recommendation  at  our  next  PPG 
meeting. One of our PPG members sits on Healthwatch Trafford, and one is a carer but registered at 
another practice. They both provide valuable insight into how they find  using the AskMyGP system 
and we will take on board any further suggestions they may also have. 

Concern 3: 

The inquest heard that he had not been seen face to face by a GP and that meant that the full extent 
ofhis deterioration was not recognised until he was seen by a paramedic from the practice who called 
an ambulance 

Response to Concern 3 

As  mentioned earlier,  we  use  EMISWeb  as  our clinical  system  and  AskMyGP to help workflow the 
requests that come into the practice. As  above,  patients  may input their requests  directly into the 
AskMyGP system, or requests can  be entered by staff for telephone or direct patient requests. The 

AskMyGp system allows an indication of whether the preferred response is email, telephone, video, a 
face-to-face consultation, or a home visit. 

All  requests for a home visit are highlighted on the AskMyGP system. Visit requests are recorded on 
the clinical system and  are initially assessed by a clinician to determine the urgency of the visit. They 
are given a high priority as a default. The allocated clinician may make initial contact by telephone to 

Page 3 of 4 

 gather the history of the presenting condition, assess urgency, and to determine how best to arrange 
for any further assessment to take place. 

We also have an emergency call handling protocol in place for staff to be aware of any life-threatening 
symptoms which should not wait for a GP call-back, but be redirected to the 999 ambulance service. 

When the practice is closed from 18:30 to 08:00 and  at weekends and  bank holidays, out of hours 
medical cover is provided by Mastercall. Anyone that calls the practice at that time is  redirected to 
the NHS 111 service. NHS 111 assess the request and direct the call to an appropriate service. If a GP 
was required out of hours, Mastercall would arrange a consultation or visit if required. 

We  acknowledge the frustrations that the family of Mr Shearer  experienced  in  trying to arrange a 
home visit. We have reviewed  our systems to make sure they are appropriately robust with respect 
to recording and prioritising of requests for consultations and home visits. It appears in the case of Mr 
Shearer there was a failure to record the family's request in the system for a home visit on 17 August 
2021. We have reminded all  reception staff of the importance of properly recording all requests for 
home visits in the clinical system so they are referred to clinicians for assessment. This requirement 
will be reinforced by the office manager in orientation and training sessions for reception staff. 

We  are  currently  looking  at  the  feasibility  of conducting  a  qualitative  survey  to  investigate  the 
experience  of patients who have  requested  home visits.  Once  we  have  developed  an  appropriate 
questionnaire, our plan is to conduct this study over the next 3 to 6 months. 

With respect to the calling of 999 for an  urgent ambulance for Mr Shearer, it has been reiterated to 
all clinical staff that upon calling 999, the clinician must remain with the patient until the arrival of the 
ambulance and until handed over to the first responder. 

We will continue to monitor the above actions in our regular practice meetings. 

Thank you  again for pr:pviding us  with your concerns.  If any further information  is  required,  please 
contact us on 0161 865 5556. 

Yours sincerely, 

Dr
GP Partners 

Page 4 of4

Private & Confidential 

F.A.O: Alison Mutch  
HM Senior Coroner   
HM Coroner’s Court  
1 Mount Tabor Street 
Stockport 
SK1 3AG 

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

Tel:   

E-mail: 

23rd June 2022   

Dear Ms Mutch,  
Re: Mr Alphonso Alexander Shearer   

I  write  in  response  to  the  Prevention  of  Future  Death  (PFD)  notice  dated  28th  April 
2022 and respond accordingly to the matters raised in relation to the death of the late 
Mr Shearer. Firstly, on behalf of Trafford Clinical Commissioning Group (CCG), I would 
like to offer Mr Shearer’s family our sincerest condolences and we hope this response 
helps to answer any questions that remain outstanding for them.  

You specifically asked us as a CCG to respond to section 5: Coroner’s Concerns, and 
we have been working with the GP’s and staff at North Trafford Group Practice (Mr 
Shearer’s GP practice) to investigate those concerns and gain an understanding of 
the learning so that we can share this with all our practices across Trafford.  

The practice has provided a full and thorough response (attached to this response) to 
each of the points raised which include the practice level learning. Our response aims 
to enhance this further to offer assurance to you and Mr Shearer’s family that we have 
considered the action taken by the individual practice and we have shared this with all 
our  practices  in  Trafford  and  encouraged  them  to  implement  the  same  systems  to 
maximise the learning and in turn, help prevent any similar experiences for our patients 
and their families.  

The CCG response to each of the concerns are provided below;    

1. 

The inquest heard that Mr Shearer was frail and vulnerable with very poor 
swallow.  When  prescribing  the  clinicians  did  not  recognise  or  have  a 
system  to  flag  up  the  need  for  liquid  antibiotics  rather  than  tablet 
antibiotics. This led to him not being able to commence antibiotics on the 
day  he  was  identified  as  needing  them.  The  inquest  heard  that  it  is 
important that in the community particularly for the vulnerable there is a 
system for recognising what form of antibiotics are most appropriate to 
prescribe to avoid delay.  

1 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
          
  
 
 
 The practice has undertaken a review of the EMISWeb system which is used by 
all practices in Trafford, this is where all patient appointments and consultations 
are recorded. The system does allow for system warning alerts (often referred 
to  by  practice  staff  as  “pop-ups”)  when  accessing  a  patient  record  to  identify 
those who may need specific types of medication based around their personal 
needs,  including  swallowing  difficulties. The practice  is now  in  the process  of 
identifying those patients who are coded with swallowing difficulties as well as 
those  who  are  already  receiving  liquid  medication,  nutritional  supplements  or 
feeds.  This  will  be  carried  out  over  the  next  4  weeks  and  for  each  of  those 
patients a “pop-up” up will be added to alert clinicians of the patient’s specific 
requirements. The practice Medicines Management Team are also supporting 
this work to help avoid any unnecessary delays in a patient’s medication. As a 
CCG we offer support with EMISWeb system to develop system alerts as well 
as  other system  capabilities  and  all  our practices  have  had the  training  to be 
able to manage this system on a day to day basis. Whilst we are not responsible 
for  the  monitoring  of  the  operational  systems  of  our  practices,  we  use  our 
quarterly educational events which practice staff attend to share any changes to 
the system and share learning from events such as this. We are really pleased 
that  the  practice  is  undertaking  this  exercise  to  ensure  patients  with  specific 
needs are managed appropriately.  

2. 

3. 

The  inquest  heard  that  the  AskmyGP  system  had  been  challenging  for 
those involved with Mr Shearer and had made communication harder. The 
evidence  identified  that  this  was  a  particular  issue  for  more  vulnerable 
patients and their families 
The inquest heard that he had not been seen face to face by a GP and that 
is meant that full extent of his deterioration was not recognised until he 
was seen by a paramedic from the practice who called an ambulance.  

The adoption of AskmyGP during 2020 was planned as part of the NHS Long 
Term Plan to improve digital access for patients. This was expedited during the 
COVID-19 pandemic due to the advantages it offered in remote working.  70% 
of our practices in Trafford use this system which has enabled patients to access 
their  practice  without  the  need  to  physically  attend  on  site  which  was 
encouraged  during  the  pandemic  where  possible.  The  remaining  30%  of  our 
practices  use  similar  digital  systems  with  the  same  capabilities.  These  digital 
systems do not mean that that face to face appointments are not available. Each 
request on these systems are reviewed by a clinician and a decision is made on 
the  method  of  consultation,  which  could  be  by  telephone,  email,  video 
consultation, face to face or a home visit.  Since the start of the pandemic all 
practices have been working in a challenging environment and had only seeing 
patients  face  to  face  where  necessary,  the  digital  system  capabilities  have 
helped to facilitate this and continues to be an effective way of managing patient 

2 

 
 
 
 
 
 
 
 
 
 
 
 
 
 requests  for  treatment.  Where  patients  are  unable  to  access  digital  systems, 
practices should offer equitable alternative access to those patients such as  
phone  calls  in  the  case  of  Mr  Shearer  and  those  phone  calls  should  be 
addressed effectively.  As part of their review of the alert system on EMISWeb, 
North  Trafford  Group Practice  are  also placing  alerts  on  the  records  of  those 
patients  who  may  struggle  with  digital  access,  this  will  include  specific 
requirements  such  as  the  need  for  an  interpreter,  or  additional  support  to 
undertake  a  consultation.  We  are  pleased  that  the  practice  is  monitoring  the 
effectiveness of this system by discussing the learning from this event at their 
next  Patient  Participation  Group,  this  group  includes  members from  our  local 
Healthwatch who act as advocates for our patient’s in Trafford. During May 2021 
the  CCG also undertook  a  review  of  the  patient experience of AskmyGP  and 
90% of the patients who had used the system were highly satisfied with it. With 
this said we are also currently undertaking a piece of work to establish who is 
using the digital systems, and more importantly who isn’t? This will enable us to 
reduce the inequalities in digital access across the borough. We will ensure that 
any learning is shared with our practices as part of this work. 

The AskmyGp system does allow for a request for a home visit and these are 
assessed  by  clinicians  to  determine  the  urgency.  The  clinician  would  usually 
make the initial contact by telephone to determine the history of the presenting 
condition and determine how best to arrange an assessment. In Mr Shearer’s 
case,  I  understand  the  family  had  difficulty  arranging  a  home  visit  and  the 
practice state that this was due to their request not being logged on the system 
on 17th August 2021 which was an error. They have reminded all reception staff 
of  the  importance  of  accurately  recording  all  requests  for  home  visits  in  the 
clinical system so that they are referred to clinicians for an assessment. This will 
be reinforced further during training sessions for reception staff. As I mentioned 
earlier  the  CCG  is  not  responsible  for  the  monitoring  of  how  our  practices 
operate  their  systems,  however  we  are  responsible  for  ensuring  our  GP 
practices  are  offering  high  quality  care  including  equal  access  across  the 
borough and support for those without digital access. This is something we will 
continue  to  monitor  via  our  current  Primary  Care  Health  Inequalities  Quality 
Aims  plan. This plan  has  been  in  place  since  November 2020 and  improving 
access to our GP practices is an ongoing theme within this.  

This  extremely  sad  case  has  highlighted  a  number  of  issues  that  can  occur  in 
healthcare systems and processes where a vulnerable patient may be at risk of a delay 
in treatment. This report gives us a real example to use in reminding all GPs in Trafford 
about those risks, what clinicians should be considering in terms of their own practice 
systems  and  the  resources  available  to  support  clinicians  in  the  management  of 
vulnerable patients with complex needs. Over the next week, we will be sharing a copy 
of  the  Regulation  28  along  with  the  responses  to  this  in  our  “Practice  Briefing”,  an 
email update which is sent out to over 400 Primary Care staff in Trafford twice a week.  

3 

 
 
 
 
 
 
 
 
 
 
 
 
 By way of further assurance, I am pleased to say that we currently have 27 practices 
in Trafford, 25 of those are rated as “Good” with the Care Quality Commission (CQC)  
and 2 are rated as “Outstanding”. The CQC process of monitoring and inspecting GP 
practices covers areas of person-centered care which takes into account the needs of  
different people and timely access to care and treatment. We don’t have any practices 
with any outstanding action plans or regulatory notices with CQC at this time, and all 
of our practices are subject to the current routine CQC monitoring process in place.  

Our Quality Team meet regularly with our local CQC Inspector to discuss any areas 
of concern and where we can support our practices maintain high quality services. We 
also  have  an  internal  Quality  Assurance  Framework  where  we  use  data  and  soft 
intelligence to enable us to monitor elements of quality with our practices on a regular 
basis.  

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

Dr 
Medical Director  

4