Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0259, written 19 Jul 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 19 Jul 2023 |
|---|---|
| Reference | 2023-0259 |
| Deceased | Michael Amesbury |
| Coroner | Alison Mutch |
| Coroner area | Manchester South |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Greater Manchester Integrated Care 1 CORONER I am Alison Mutch, Senior Coroner, for the Coroner Area of Greater Manchester South 2 CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 3 INVESTIGATION and INQUEST On 6th December 2022 I commenced an investigation into the death of Michael Kevin Amesbury. The investigation concluded on the 25th May 2023 and the conclusion was one of Narrative: Died from a combination of bronchopneumonia (not diagnosed until after death) and aspiration of gastric contents exacerbated by heart failure for which he was awaiting assessment regarding his suitability for surgical intervention. The medical cause of death was 1a) Bilateral Bronchopneumonia and aspiration of gastric contents; II) Heart Failure, Diabetes Mellitus, Dapagliflozin therapy 4 CIRCUMSTANCES OF THE DEATH Michael Kevin Amesbury had an extensive cardiac history. He was becoming increasingly unwell as a consequence. On 24th October 2022 he had a trans-oesophageal echocardiogram that confirmed he had severe mitral regurgitation. He was referred to Wythenshawe Hospital for surgical assessment. Whilst awaiting assessment he became increasingly unwell. He was prescribed Dapagliflozin medication which led to a rapid rise in his ketones and he became increasingly unwell. He was admitted to Tameside General Hospital on 30th November 2022 .Whilst an in-patient at Tameside General Hospital he became unresponsive. Cardiopulmonary resuscitation was undertaken during which there was severe vomiting of gastric contents. He died at Tameside General Hospital on 30th November 2022. Post-mortem examination confirmed he had died from bilateral bronchopneumonia (not diagnosed in life) in combination with extensive aspiration of gastric contents. He had extensive evidence of heart failure which on the balance of 1 possibilities contributed to his reduced physiological reserves and to his death. 5 CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. – 1. The inquest heard evidence that Mr Amesbury needed to be referred from secondary to tertiary services within Greater Manchester. The inquest heard evidence that the speed and quality of that referral was impacted by the way in which information was shared between clinicians in different trusts within Greater Manchester. The use of different systems and reliance on postal services and lack of a clear, effective electronic system of referrals including transfer of images /notes meant there were delays in assessing patients which led to a delay in formulating a treatment plan in tertiary services; 2. The evidence also indicated that there were delays in patients who had been identified as requiring cardiology input being seen in cardiology clinics due to availability of clinicians/appointment slots inquest. This was exacerbated where there was a need for trans- oesophageal echocardiogram due to resource issues. The inquest heard that this type of echocardiogram could be key in understanding the cardiac issues of a patient. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 13th September 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely 1) on behalf of the Family; 2) Tameside General Hospital; 3) Wythenshawe Hospital, 2 who may find it useful or of interest. I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 9 Alison Mutch HM Senior Coroner 19.07.2023 3
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Date: 06/10/2023 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 Thank you for your Regulation 28 Report dated 19th July 2023 concerning the sad death of Michael Kevin Amesbury on the 30th November 2022 . On behalf of NHS Greater Manchester Integrated Care (NHS GM), we would like to begin by offering our sincere condolences to Mr. Amesbury’s family for their loss. Thank you for highlighting your concerns during Mr. Amesbury’s Inquest which concluded on 25th of May 2023. NHS GM, we apologise that you have had to bring these matters of concern to our attention. We recognise it is very important to ensure we make the necessary improvements to the quality and safety of future services. Following the inquest, you raised concerns in your Regulation 28 Report to NHS GM that there is a risk a future death will occur unless action is taken. The medical cause of death was 1a) Bilateral Bronchopneumonia and aspiration of gastric contents; II) Heart Failure, Diabetes Mellitus, Dapagliflozin therapy I hope the response below demonstrates to you and Mr Amesbury’s family that NHS GM has taken the concerns you have raised seriously and we will learn from this as a whole system. This letter addresses the issues that fall within the remit of NHSGM and how we can share the learning from this case. The inquest heard evidence that Mr Amesbury needed to be referred from secondary to tertiary services within Greater Manchester. The inquest heard evidence that the speed and quality of that referral was impacted by the way in which information was shared between clinicians in different trusts within Greater Manchester. The use of different systems and reliance on postal services and lack of a clear, effective electronic system of referrals including transfer of images /notes meant there were delays in assessing patients which led to a delay in formulating a treatment plan in tertiary services. Inter-operability of different information technology systems to enable efficient and effective communication across primary care, secondary care, tertiary care and wider system partners continues to be a challenge for all health and care systems nationally. Interoperability of systems between tertiary and secondary care is a difficult issue that we have been 4th Floor, Piccadilly Place, Manchester M1 3BN Tel: 0161 6257791 www.gmintegratedcare.org.uk exploring. Attached as appendix 1 is a briefing note which outlines how a secondary to tertiary referral platform (Patient Pass) has been used to excellent effect in Renal, Neurosurgery and Plastics services at Northern Care Alliance (NCA). There are significant benefits for outcomes re safety and productivity. We are looking at how we can bring the benefits of this type of technology to other services. Health and social care organisations in Greater Manchester have established the GM Care Record (GMCR), a shared care record which amalgamates essential information for 2.8 million citizens and is used by health and social care professionals for direct care across the region’s 10 localities. However the GMCR does not address system operability between tertiary and secondary care, therefore we must procure this through alternative suppliers e.g. Patient Pass. The GMCR can sit alongside this technology. Work to resolve this aligns closely with the GM digital strategy, the opportunities that the ICB brings for visibility, spread and scale. GM ICB commits to exploring and as appropriate, implementing this across other GM services. We will be progressing this with chief information officers across the integrated care system for an outline discussion to consider how this could be worked up into a funded project within the strategy delivery plan. The evidence also indicated that there were delays in patients who had been identified as requiring cardiology input being seen in cardiology clinics due to availability of clinicians/appointment slots inquest. This was exacerbated where there was a need for trans- oesophageal echocardiogram due to resource issues. The inquest heard that this type of echocardiogram could be key in understanding the cardiac issues of a patient. Radiologist shortages are being experienced nationally, with a 15% vacancy rate across Greater Manchester at consultant grade. The Greater Manchester Imaging Network are supporting the upskilling and change of skill mix within the Imaging workforce by allocating funding for reporting radiographers, focusing on computerised tomography (CT) and magnetic resonance imaging (MRI) reporting radiographers. Furthermore, the network are coordinating international recruitment via community diagnostic centres (CDC) funding stream to bring in more radiologists. The Imaging network are exploring the use of a collaborative staff bank, including CT, to reduce reliance on agencies etc. Also, the use of Picture Archiving and Communication System (PACS) based reporting in future will be an enabler for an insourcing model or more centralised service to be used for reporting. PACS are Picture and Communication Systems, which provide economical storage and convenient access to images from multiple modalities and could therefore be used as central storage systems that can be used across GM, reducing the staffing resource required to do the reporting. The implementation of PACS is currently a key scheme within the Imaging Digital Programme. Actions taken or being taken to share learning across Greater Manchester: 1. Learning to be presented/shared with the Greater Manchester System Quality Group on the 16 of November 2023. This meeting is attended by a broad range of system leaders, including, clinical and care leaders, commissioners of specialist services, locality representatives from each of the 10 GM boroughs, the CQC, Healthwatch who represent the public voice and NICE. Through sharing in this forum, we expect members to review and ensure learning is incorporated into their commissioned services. 4th Floor, Piccadilly Place, Manchester M1 3BN Tel: 0161 6257791 www.gmintegratedcare.org.uk 2. To discuss at the GM Digital Delivery Executive in October 2023 for an outline discussion to consider how this could be worked up into a funded project within the strategy delivery plan. 3. Shared learning from this and similar cases at Greater Manchester and borough level will be cascaded to professionals through relevant governance and learning forums to ensure that learning is incorporated into their services. 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. Amesbury’s family that NHS GM has taken the concerns you have raised seriously and is committed to working 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 our attention and please do not hesitate to contact me should you need any further information. Yours sincerely Chief Nursing Officer GM Integrated Care Place Based Lead Tameside GM Integrated Care 4th Floor, Piccadilly Place, Manchester M1 3BN Tel: 0161 6257791 www.gmintegratedcare.org.uk Appendix 1: Proposed model to scale and spread Briefing Paper - Regional Clinical Collaboration Platform Context The Northern Care Alliance (NCA) hosts multiple tertiary and quaternary services that deliver in-patient and out-patient care. In 2016 renal and neurosurgery had experienced episodes of patient harm due to miscommunication and/or lost communication between referring trusts and the specialist teams. These resulted in His Majesty’s Coroner issuing Prevention of Future Death Requirements. Initial assessment Discovery work (including consultation with key regional stakeholders) highlighted key issues that formed the basis of organisational requirements. Selected issues are shown below: Issue Identified Verbal (phone) advice was not consistently documented between referring site and speciality teams Lack of clear ownership of actions and activities to progress patient care Uncertainty around patient transfers between sites Delays in documentation complicating clinical audit trail Significant loss of productive clinical time at all sites (time to response often > 30mins; full time senior doctor employed to take calls) Gaps in coordination of care between in-patient and out-patient care for sub- acute cases who required clinic follow up No organisational understanding of the volume of work supported by clinical teams Requirement(s) Single, shared version of the truth that can be updated Ability to export into core systems of record Task list with clear accountability for action within the system Single shared list of pending transfers with patient information protected by Role-based access control (RBAC- a mechanism that restricts system access) Comprehensive time stamped audit trail Time efficient web accessible referral tool (target <3 mins to make a referral) that enables both real time and asynchronous communication Ability to use information within the system to generate referrals for out-patient care in speciality / sub-speciality clinics In platform reporting to describe service activity and alignment with key performance indicator e.g. time to referral Solution procurement No existing system was identified in the trust that met the clinical requirements of referring clinicians and speciality clinicians. Initially the trust procured a digital platform, called NORSE. This was implemented but withdrawn after a supported 6 month trial. Within the Salford Global Digital Exemplars programme a follow on pilot using Patient Pass was deployed into renal services. Evaluation of the pilot showed significant benefits and received positive feedback from regional colleagues. A competitive tender was issued to fully assess the market, following which the NCA formally procured Patient Pass across multiple services. This contract has since been renewed and extended. Realised benefits 4th Floor, Piccadilly Place, Manchester M1 3BN Tel: 0161 6257791 www.gmintegratedcare.org.uk Patient Pass is now an established system within the NCA, with over 12,000 registered users within GM. For the NCA, the platform supports in excess of 25,000 patient referrals each year. Selected benefits realised from this include: 1. Medicolegal – there have been no further episodes of patient harm to delays in or ambiguity within clinical communications 2. Clinical staff release – within renal, deployment of Patient Pass has allowed the release of 20 hours of a speciality registrar. This has increased outpatient department clinic capacity, improved training opportunities and job satisfaction. 3. Increased referral volumes – appropriate referrals have increased identifying a prior unmet demand due to challenges in accessing specialist advice 4. Improved transfers – shared visibility of transfer lists has enabled more efficient transfers into specialist beds and allows more coordination of transfer / repatriation activity 5. Greater control over the management of high risk patients – during the pandemic, renal services were able to avoid the transfer of transplant patients through enhanced communication with other clinical teams. These benefits have supported ongoing work including embedding the system within the Sunrise electronic patient record and development of capabilities to enable virtual, asynchronous clinical multi- disciplinary team (MDT ). Approximately 50-70 patients are considered each week in the virtual neuro- oncology MDT using this platform. Feedback from NCA and Christie clinicians has been very positive. Meeting time has been reduced and analytics are being developed to support automatic pathway reporting and tracking to enable targeted service improvement. Opportunity The opportunity exists to scale and spread this model of care within the GM ICS, leveraging the installed user base and existing clinical pathways. Deployment at an ICS level would enable complex case transfers and out-patient planning to be managed at a higher and more efficient level, allowing resource sharing and joint input. Local use of Patient Pass is now further enhanced by access to information held within the Greater Manchester Care record and the GM picture archiving and communication system (PACS). For selected services this allows a consultant to review and input into approximately 20 case records per hour. Further information Patient Pass is featured in the NHSx Renal Digital Playbook: https://transform.england.nhs.uk/key-tools-and-info/digital-playbooks/renal-digital-playbook/digital- referral-system-to-improve-patient-access-to-renal-services/ Vendor case study – NCA Plastic https://patient-pass.s3.amazonaws.com/docs/case-studies/Plastics_NCA.pdf Vendor case study – Leeds Teaching Hospitals https://patient-pass.s3.amazonaws.com/docs/case-studies/Leeds.pdf 4th Floor, Piccadilly Place, Manchester M1 3BN Tel: 0161 6257791 www.gmintegratedcare.org.uk
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