Philip Jones

a

Department
of Health &
Social Care

Ms Alison Mutch

HM Senior Coroner
Coroner’s Court

1 Mount Tabor Street
Stockport

SK1 3AG

¢ pri 2023

Dear Ms Mutch,

Thank you for your letter of 17 August 2022 about the death of Mr Philip Jones. | am
replying as Minister with responsibility for Health and Secondary Care, and thank you
for the additional time allowed.

Firstly, | would like to say how saddened | was to read of the circumstances of Mr
Jones’s death, and | offer my sincere condolences to his family and loved ones. The
circumstances your report describes are very concerning and | am grateful to you for
bringing these matters to my attention.

In preparing this response, Departmental officials have made enquiries with NHS
England, Health Education England, and the Care Quality Commission (CQC).

The pandemic has put enormous pressures on the NHS, with elective waiting lists
growing to nearly 7.2 million patients, however, we remain committed to ensuring
people get the right care at the right time. During the peak of the pandemic in the first
wave, we focussed on caring for COVID-19 patients while also prioritising urgent
treatments like surgery for cancer and other lifesaving operations. To prevent the NHS
from becoming overwhelmed and ensure it could deliver the essential services needed
to deal with COVID-19, NHS England issued guidance to postpone all non-urgent
elective activity for three months.

| recognise, however, that this step resulted in a large number of cancelled and
postponed appointments and procedures, including patients waiting to see a
neurology specialist. | appreciate this must have had a significant impact on a huge
number of people across the country, many of whom were experiencing pain or anxiety
whilst waiting. While every effort was taken to deliver as much NHS activity as
possible, there have undoubtedly been unfortunate and tragic consequences as a
result of the pandemic. Indeed, in subsequent COVID-19 waves and in the winter of
2021-22, every effort was made by the NHS not to pause planned treatment.

Al

That is why the NHS is working tirelessly to reduce the backlog of planned treatment.
In February 2022, the NHS published its Delivery Plan for Tackling the COVID-19
Backlog of Elective Care.’ This plan sets out the action that will be taken and is already
underway to support the healthcare system in England as it recovers from the
disruption caused by the pandemic, as well as to deliver the necessary reforms that
are important to the NHS’s long-term future. In order to support elective recovery, the
Government plans to spend more than £8 billion from 2022-23 to 2024-25, in addition
to the £2 billion Elective Recovery Fund, and £700 million Targeted Investment Fund
already made available to systems last financial year to help drive up and protect
elective activity.

| also note your concern about the shortage of neurological clinicians. We have
increased the size of the NHS workforce over the last decade and this growth
continues to be a key focus to ensure we meet the rise in demand for health and care
services. Looking at the workforce of the future, the Department has commissioned
Health Education England to work with system partners and review long term strategic
trends for the health and regulated social care workforce, and have commissioned
NHS England to develop a long-term workforce plan.

In response, Health Education England are leading and driving a system-wide effort
to mitigate the impact of the pandemic on the significant NHS care backlog across
regions through the Training Recovery programme established in April 2021. This
includes: effective planning to utilise the trainee workforce, recognising their breadth
of experience and capability, and offering training opportunities while doing so;
working through regional and local teams to identify additional post capacity and to
optimise training opportunities to reduce the number and duration of any extensions
to training that would slow down the progression to consultant; the Postgraduate
Medical Training Recovery Programme, that will safeguard the continuous supply of
the medical workforce and ensure that the content and product of postgraduate
medical education and training responds to the current and future needs of patients
and local communities.

| also note your concern that incompatible IT systems between the hospitals in
question made communication and information sharing in relation to Mr Jones’s
treatment more difficult, as did the delay in the consultants communicating with other
clinicians, including GPs, and as well as the patients themselves. | recognise that
there needs to be adequate administrative support and greater use of digital
technology to assist healthcare workers in completing non-clinical tasks, and that
could increase the time they can spend caring for patients. This would provide a better
patient experience and, ultimately, improve health outcomes. With new technologies
based on Artificial Intelligence and automation, as well as those we recognise more
from our daily lives like video calls, we are building a digital infrastructure that will
ensure the NHS is at the cutting edge of progress for years to come.

You may wish to note that the Spending Review, announced in Autumn 2021, included
£2.1 billion to modernise digital technology on the frontline to improve cyber security,
improve the NHS’s use of data, and redesign care pathways. As well as a funding

1 https:/Avww.england.nhs.uk/coronavirus/wp-content/uploads/sites/52/2022/02/C1466-delivery-plan-
for-tackling-the-covid-19-backlog-of-elective-care.pdf

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boost, the Government and NHS England published its Plan for Digital Health and
Social Care in June 2022.? This plan includes:

e Digitising health and social care records - all integrated care systems (ICSs) and
their NHS trusts are aiming to have core digital capabilities, including electronic
health records, in place by March 2025.

e A life-long, joined up health and social care record — by March 2025, all clinical
teams in an ICS will have appropriate access to a complete view of a person’s
health and social care record that they can contribute to. Non-clinical staff in social
care settings will also be able to access appropriate information and input data into
digital records in real time.

e Digitally-supported diagnoses — new diagnostics capacity is being developed to
enable image-sharing and clinical decision support based on Artificial Intelligence.
These technologies support testing at or close to home, streamlining of pathways,
triaging of waiting lists, faster diagnoses and levelling up under-served areas.

This will ultimately mean that GPs, as well as other treating clinicians, will have greater
access to a complete patient record and be able to communicate treatment plans and
outcomes to patients in a more timely and comprehensive way.

Finally, the CQC has confirmed that they continue to monitor safety and performance
at both the Northern Care Alliance Trust and the Tameside and Glossop Integrated

Care NHS Foundation Trust, through the analysis of data and intelligence and through
regular engagement.

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

Oily Sue

WILL QUINCE MP
MINISTER OF STATE FOR HEALTH

? https://www.gov.uk/government/publications/a-plan-for-digital-health-and-social-care/a-plan-for-
digital-health-and-social-care

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Date: 11 October 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 – Philip Jones 09/10/21 

Thank you for your Regulation 28 Report dated 17/08/22 concerning the sad death of Philip Jones on 
09/10/21. On behalf of NHS Greater Manchester Integrated Care (NHS GM), I would like to begin by 
offering our sincere condolences to Mr Jones family for their loss. 

Thank you for highlighting your concerns during Mr Jones Inquest which concluded on 30 May 2022. On 
behalf of NHS GM, I apologise that you have had to bring these matters of concern to our attention but it 
is also very important to ensure we make the necessary improvements to the quality and safety of future 
services. 

The inquest concluded that Philip’s death was a result of 1a) Bronchopneumonia; 1b) Motor Neurone 
Disease. Following the inquest, you raised concerns in your Regulation 28 Report to NHS GM that there 
is a risk future deaths will occur unless action is taken. 

I hope the response below demonstrates to you and Mr Jones family that NHS GM has taken the 
concerns you have raised seriously and will learn from this as a whole system. 

This letter addresses the issues that fall within the remit of NHS GM and how we can share the learning 
from this case. 

Matter 1. The Inquest heard evidence that there were significant backlogs in appointments to see 
a neurologist due to a national shortage of clinicians and appointments. In Mr Jones’ case this had 
not impacted the overall outcome but the Inquest heard evidence that this would not necessarily be the 
case in all patients. The Inquest heard that pre-pandemic, there was a backlog in existence at 3,500 
patients waiting for a neurology appointment. The figure at the time of the Inquest was appro x. 7,000; 

Following the COVID 19 pandemic the waiting list for a new appointment in Neurology has significantly 
grown to in excess of 10,000 patients waiting across GM with a wait time of 52 weeks for a routine 
appointment. Neurology do however have a robust triage process in place for all referrals into the service 
and any deemed as clinically urgent are being prioritised and booked within a 4 -6 weeks. Pre-pandemic 
the waiting list for Neurology on average stood between 3000-4000 patients with a wait time of 12-18 
weeks for routine appointments, this however was heavily reliant on Locum consultants holding super 
clinics each weekend along with additional WLI consultant clinics. 

4th Floor, Piccadilly Place, Manchester M1 3BN 
Tel: 0161 6257791  www.gmintegratedcare.org.uk 

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 Following government guidelines all face to face activity during the pandemic was stood down and 
appointments converted to telephone consultations, this resulted in the locum clinics ceasing and a 
backlog of patients who needed reviewing post telephone appointment for examination impacting on the 
available clinic capacity remaining.  We were also impacted by loss of clinic room capacity as a result of 
social distancing guidelines which continues to be an issue for us as a service. 

The Neurology service has always had more referral demand than capacity, our current capacity 
modelling reflects an approx. deficit of 1500 new patient slots per month. A comprehensive action plan 
detailing the steps being taken as a service to bring down the current waiting list to acceptable levels 
(attached) has been developed and the current situation is scoring highly on the trust risk register. (Copy 
attached). 

Recruitment of substantive clinicians is ongoing along with reinstating the use of locum capacity. 

Matter 2. The Inquest heard evidence that incompatible/different IT systems at the District 
General Hospital and Tertiary Centre made communication and information sharing in relation to 
patients more difficult. This impacted the holistic view that clinicians needed of an individual 
patient. Whilst images could be shared there was no ability for notes for one Trust to be visible to 
a clinician at another Trust; 

Consultant Neurologists hold clinics across GM and have access to both the Salford IT systems and the 
District General Hospital IT systems where they are based. There are occasions where patients choose 
the site in which they have their outpatient appointments, and this may not be the site most local to them. 
This can result in information not being available to the consultant at the time of consultation. 

The facility to share clinical records between separate NHS Trusts is not unique to this organisation and 
the tertiary centre. The Trust is proactively working towards transfer to an electronic patient reco rd as 
outlined within the NHS Long Term Plan, with the oversight of their Chief Clinical Information Officer. The 
digitisation of patient clinical records will provide an opportunity for sharing of information between 
organisations and the Trust is committed to progression of the digitisation agenda in line with national 
ambition. 

Matter 3. The Inquest heard that there were delays in communications from consultants to other 
clinicians e.g. GPs and patients following appointments/assessments due to a shortage of 
administrative support for consultants. This meant that important diagnostic/treatment 
information about patients was not shared expeditiously. 

Within the centralised Booking and Scheduling and Secretarial and Administration department at 
Tameside there are robust management measures in place to ensure that possible delays are identified 
and managed proactively. The management team, which is part of our Clinical Support Services 
Division, oversee and coordinate the booking and scheduling of theatres and endoscopy procedures, 
secretarial and administration of all clinical typing, to ensure that patients treatment and communications 
are not delayed and the patient is retained our central focus. 

4th Floor, Piccadilly Place, Manchester M1 3BN 
Tel: 0161 6257791  www.gmintegratedcare.org.uk 

Neurology Waiting List Action Plan.docxRisk Register 7167.pdfB2 
  
 
 
 
  
 
   
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 Current typing standards (Key performance indicator) is for 95% of clinical letters to be typed within five 
days of the appointment. The review confirmed that this target was met in Mr Jones’ care. Secretarial 
and administration managers review typing performance and administration work daily and the 
coordinated approach taken by the Trust allows for the transfer of resource to cover areas such as 
absence. Any risks are identified with appropriate plans made with divisional escalation.  Further to this, 
daily management meetings are held to undertake a continuous review of performance, workload and 
any emerging concerns or risks relating to staffing, including absences. With a centralised team there is 
the ability to move colleagues to areas as needed to close any gaps or to support in additional workload 
to resolve any risks or provide cover in times of additional need or surge. Any vacancies are discussed in 
these daily meetings to ensure that they are advertised without delay to minimise service disruption and 
maximise patient safety and experience. Performance relating to their communication with external 
partners such as GP’s, other Trust’s or care providers and patients is overseen through divisional 
mechanisms, with any exceptions or delivery challenges shared at Oper ational Board and considered 
through the lens of quality, safety and Experience through the Trust Service Quality and Assurance 
Group. 

Actions taken or being taken to share learning across Greater Manchester. 

1.  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 and NICE. 

2.  Shared learning from this and similar  cases at  Greater Manchester and borough level will be 

cascaded to professionals through relevant governance and learning forums. 

In conclusion, key learning points and recommendations will be monitored to ensure they are embedded 
within practice. NHS GM is committed to improving outcomes for the population of Greater Manchester. 

I hope this response demonstrates to you and Mr Jones family that NHS GM has taken the concerns you 
have raised seriously and is committed to work together as a system including our service users, carers 
and families to improve the care provided. 

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 

Chief Nursing Officer 
NHS Greater Manchester Integrated Care 

4th Floor, Piccadilly Place, Manchester M1 3BN 
Tel: 0161 6257791  www.gmintegratedcare.org.uk 

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