Teresa Chmielek

Corporate Services 
Trust Headquarters 
225 Old Street 
Ashton Under Lyne 
Lancashire 
OL6 7SF 

15 January 2024 

Private & Confidential 
MS Joanne Kearsley 
HM Senior Coroner 
HM Coroner’s Court 
Floors 2 & 3, Newgate House, 
Newgate 
Rochdale 
OL16 1AT 

Dear Ms Kearsley 

Ref: Inquest touching on the death of Ms Teresa Chmielek 

I  write  in  response  to  your  Regulation  28  report  dated  24  November  2023,  and  in 
respect of the concerns you have highlighted after hearing evidence at the Inquest of 
Ms Teresa Chmielek on 23 November 2023. 

I was sorry to learn that following witness evidence, you had concerns which had not 
been  addressed.  Your  concerns  have  been  reviewed  and  I  understand  that  this 
prompted  a  deep  dive  into  the  service  and  processes  used, facilitated  by  our 
Network  Director  of  Quality  for  the  North.  This  process  has  informed  our  response 
and I have summarised the main points of this here for assurance. 

The  Deep  Dive  used  a  process  mapping  approach  and  as  a  result,  a  number  of 
changes to the Single Point of Entry (SPoE) function in Oldham. I am advised that to 
provide  some  objectivity  to  the  process,  an  external  lens  was  applied  by  a  subject 
matter expert in relation to the SPoE function in Old  Age care, with representatives 
from  the  team,  members  of  the  leadership  team,  medical  staff  and  quality 
representation. 

We have recognised that the SPoE function needs greater integration into the wider 
Old  Age  provision,  rather  than  as  a  separate  function.  This  is  now  in  place.  The 
SPoE function is an integral part of the Home Intensive Treatment Team (HITTS) to 
ensure  that  this  is  activity  undertaken  by  the  team  and  not  an  individual  function. 
Alongside  this,  the  Multidisciplinary  Team  (MDT)  meeting  has  been  reviewed  and 
processes  have  been  introduced  to  administer  this  meeting,  with  all  decisions 
recorded  on  our  electronic  patient  record,  with  an  audit  function  to  support.  This 
should ensure that the process is more robust. 

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 final  draft,  and  this  covers  all  processes  required, 

A standard operating procedure (SOP) has also been introduced, which is now at the 
the 
stage  of 
administration  of  a  referral,  gaining  additional  information,  speaking  to  the  patient  / 
family  (when  this  needs  to  be  face  to  face),  the  role  of  the  meeting  and  outcome 
letters to GPs and families. 

including 

Finally,  as a  result  of your concerns and  the  findings  from the  deep  dive, the  Trust 
have  commissioned  a  fact-finding  investigation  under  the  Trusts  Disciplinary  Policy 
in relation to actions taken or not taken by the SPoE Nurse. This process is currently 
ongoing.  While  this  continues,  steps  have  also  been  taken  to  ensure  the  correct 
support  is  in  place  for  all  team  members  and  the  supervision  of  staff  has  been 
reviewed.  To  reflect  the  integration  of  this  function,  there  is  capacity  for  regular 
review of individual cases within the supervision sessions. We hope that this should 
also  further  strengthen  our  internal  system  of  controls  and  assurances,  but  also 
minimise  the  possibility  of  other  patients  experiencing  the  concerns  that  you  have 
shared with us. 

Matters of concern: 

1)  The  notes  made  by  the  SPoE  Nurse  for  use  during  discussion  at  the 
screening MDT meeting did not include any reference to the report of a 
recent suicide attempt and the Court was not satisfied that the risk of 
suicide had been identified or recognised by the SPoE Nurse. 

As  mentioned  earlier  in  this  response,  we  have  developed  a  SOP  which  outlines 
processes  to  be  followed  in  Oldham  to  ensure  the  administration  of  the  referral, 
assessment  of  the  patient  and  engagement  with  families  is  all  presented  at  the 
MDT  Meeting.  Decisions  and  outcomes  are  recorded  on  the  electronic  patient 
record. The SPoE function in Oldham is now integrated into the wider HITTs team 
and  the  MDT  meeting  has  been  reviewed,  to  ensure  wider  representation  with 
clarity  of  roles  participating  and  format  of  the  meeting.  Full  referral  details  and 
outcomes of assessments/ discussion with families are shared in the MDT Meeting. 

It  is  anticipated  that  these  changes  should  minimise  the  opportunity  for  important 
information or risk factors, such as those outlined, to be omitted. This learning will 
be shared with other teams within the Network and across the Trust to ensure that 
any transferable learning from these events and changes are understood. 

2)  The Court heard that the practice at the screening MDT meeting was for 
the  SPoE  Nurse  to  read  out  the  contents  of  the  referral  to  the 
Psychiatrist  who  would  then  advise  on  next  steps.  There  was  no 
evidence  to  show  that  any  form  of  meaningful  multi-team  discussion 
took place at the screening MDT meeting. 

Our review of the MDT meeting has changed  the format of  the joint meeting.  The 
SPoE function is integrated into the wider HITTs team and the representation at the 
MDT has been extended. The Trust SOP now articulates expectations at the MDT 
meeting,  and  all  decisions  will  be  documented  on  the  electronic  patient  record, 
along with a record of the discussion. It is regrettable that this was not in place at 

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 the  time  of  the  inquest,  but  it  is  considered  that  this  should  provide  an  auditable 
means of demonstrating the quality of our care. 

3)  There  was  no  direct  contact  between  the  mental  health  team  and  the 
Deceased  (either  by  telephone  or  in  person)  before  the  decision  to 
reject the referral was made. 

As  reflected  in  the  introduction  to  our  response,  the  deep  dive  review  conducted 
identified  a  number  of  recommendations  for  change  and  the  SOP  reflects  those 
improvements. The administration  of  the  referral is covered  in  the SOP  with clear 
guidance on how to obtain further information on the patient’s presenting condition. 
This  includes  a  discussion  with  the  patient  and  their  families  where  appropriate, 
prior to the MDT discussion. All discussions, decisions and assessments will be on 
the  electronic  patient  record.  These  changes  will  be  shared  with  the  team  by  the 
service manager. 

4)  The  Consultant  Psychiatrist  present  at  the  MDT  meeting  has  no 
recollection of discussing the referral and whilst the evidence was that a 
letter  to  the  GP  practice  explaining  the  reason  for  rejecting  the  referral 
was generated, there is no record of this letter on the Trust's electronic 
systems or having been received by the GP practice. 

As  part  of  our  review process,  a  number  of  changes  have  been  made  to  the  MDT 
meeting, including wider representation. A process to support the meeting has been 
reviewed  and  all  discussion  and  decisions  are  recorded  on  the  electronic  patient 
record. The SOP includes instructions relating to outcome letters to GP, patients and 
families.  The  electronic  patient  record  can  be  audited  to  understand  and  monitor 
compliance  with  this  requirement,  allowing  for  action  to  be  taken  by  the  leadership 
and  quality  teams  where  good  or  poor  practice  is  identified.  Now  the  function  is 
integrated  into  the  wider  team,  supervision  arrangements  are  in  place  which  allow 
space and time for discussion of specific cases. 

5)  The evidence was that there is no member of staff allocated to deal with 
referrals  when  the  SPoE  Nurse  is  absent  from  work  which  means  that 
during their absence, urgent referrals are not being reviewed. 

Further  to  the  evidence  heard  at  inquest,  the  deep  dive  highlighted  that  any 
arrangements  in  place to cover absence or  leave were not robust. As  you are now 
aware from our response, the function is no longer a stand-alone role and therefore 
as part of a wider team, cover for absences can be planned, increasing resilience. 

6)  There  is  currently  no  Standard  Operating  Procedure  on  how  referrals 

into the SPoE Older Adults should be managed. 

While  not  in  place  at  the  time  of  the  inquest,  a  Standard  Operating  Procedure  has 
been  drafted,  with  input  from  operational  staff  and  is  currently  under  final  review. 
Once  this  has  been  ratified,  this will  be  shared  with  teams  by the  service  manager 
with communication of our expectations for use. 

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 7)  There is currently no system by which the management of referrals into 
the  SPoE  and  related  decision-making  are  audited.  As  such  there  is  a 
risk that poor quality decision-making is going unchecked. 

As  outlined  in  response  to  the  earlier  points,  all  decisions  and  discussion  can  be 
entered onto the electronic system, which can be audited.  The decision to integrate 
the function into the team allows for case-by-case supervision for practitioners which 
should add additional support for staff and oversight. 

I am sorry that you had cause to raise concerns with us directly at the conclusion of 
Ms Chmielek’s inquest and I trust this response assures you that we have taken your 
concerns seriously and have thoroughly reviewed the issues raised. 

Yours sincerely 

Executive Director of Quality, Nursing & Healthcare Professionals/Deputy CEO 

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