Alan Smith

Stockport Integrated Care Partnership              

4th Floor, Stopford House 
Piccadilly 
Stockport 
SK1 3XE 

Date:  8 May 2024  

Private & Confidential 
Ms Alison Mutch  
H M Senior Coroner for South Manchester  
1 Mount Tabor Street 
Stockport 
SK1 3AG  

Dear Ms Mutch  

Prevention of Future Deaths Report re Mr Alan William Rowland Smith 

I refer to the Regulation 28 Report issued following the inquest into the death of the above 
named.  I am sorry to learn of the circumstances of Mr Smith’s death and would ask that you 
pass on my sincere condolences to his family.  

During the inquest you identified a number of causes for concern which I will now address 
in order:- 

(1) 

The  inquest  heard  evidence  that  a  prompt  referral  to  Vascular 
Services  was  important  in  cases  such  as  these,  where  GPs  would  have 
limited expertise in managing the risks and offering effective treatments.  
The need for early referral was not, the inquest was told, widely understood 

Following the inquest and the issuing of the Regulation 28 in this case, the GP partners have 
undertaken a full review of Mr Smith’s journey of care, focusing on the timing of referrals 
into specialist services including referrals to the vascular surgery team.  The practice maintain 
that the management of Mr Smith’s leg swelling was appropriate.   

In circumstances where a GP has a query in relation to a leg swelling and whether to refer 
into vascular surgery, the process is for a referral to be completed so that the vascular team 
can then triage and determine if the patient is appropriate for them and / or to advise on the 
way forward.   

In light of the findings in this case, a Masterclass learning event will be delivered in September 
2024 to include advice and guidance in relation to the circumstances in which to refer and 
the  information  required  within  a  referral  to  ensure  timely  triage  and  progression  to  care 
under the vascular surgery team as appropriate. 

 
 
 
                    
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
    
 
 (2) 

Where  such  referrals  were  made,  it  was  essential  that  sufficient 
information  be  provided  to  ensure  that  the  degree  of  risk  could  be 
accurately assessed and effective prioritisation could take place 

It  is  expected  that  any  referral  into  any  specialist  service  will  be  complete  to  include  all 
relative information to enable the team reviewing / triaging the referral to do so in a timely 
manner.  In circumstances where a referral is processed but the team are unable to promptly 
triage due to insufficient information, the referral is rejected with details of the information 
or action required in order to progress.   

The  Masterclass  training  event  being  put  in  place  will  include  reference  to  ‘what  a  good 
referral into this service should look like.’   

(3) 

The  inquest  was  told  that  as  well  as  referral  to  vascular  services  it 
was  important  that  GPs  understood  that  District  Nurses  were  a  resource 
that should be utilised with prompt referrals. This could be challenging as 
the  District  Nursing  Service  was  under  huge  pressure  due  to  demand. 
However, they were well used to recognising high risk patients and clearer 
guidance for GPs around when to refer would ensure that their expertise 
would be available at an early stage. Management of any case such as Mr 
Smith’s  would  of  necessity 
involve  the  District  Nursing  Team  as 
compression  bandaging  was  the  most  effective  treatment  to  prevent  a 
critical  situation  such  as  Mr  Smith’s  arising  and  the  District  Nurses  were 
best  placed  to  provide  this.  In  Mr  Smith’s  case  the  referral  for  District 
Nursing  input  was  not  until  a  very  late  stage  even  though  the  GP  had 
identified at an early appointment that compression would be of benefit.  

Regardless of the level of demand on the District Nursing (DN) Team, all referrals  are triaged 
and prioritised appropriately so that patients are seen in order of clinical need.  The service 
confirm that they welcome enquiries from their GP colleagues and where an enquiry indicates 
the potential need for a DN visit this is arranged. 

The GP referral to the DN in this case was made on 17 August 2023 for urgent assessment 
of Mr Smith’s leg and on the following day a member of the DN team attended Mr Smith at 
his home to carry out a full assessment. This included taking wound swabs for culture and 
sensitivity testing and with consent to the taking of photographs. Contact was made with the 
GP and antibiotic therapy was commenced.  A senior district nurse attended the following 
day and a regular pattern of visits was agreed.   

The  GP  Practice  have  undertaken  a  review  of  this  case  and  explain  that  the  referral  was 
processed when infection and ulceration was noted.  Prior to that  Mr Smith’s bilateral leg 
swelling was managed with a trial of diuretics, prescribed compression hosiery and advice to 
elevate the legs where possible which is the appropriate management.  

                                                                                                                                               
 
 
  
 
 
 
 
 
 
 
 
 I  am  satisfied  that  when  the  GP  identified  the  potential  benefit  of  compression,  suitable 
compression  hosiery  was  ordered  for  him  and  the  referral  to  the  DN  Team  made  when 
clinically indicated. 

Your inquest highlighted that GPs generally could benefit from additional training to enable 
consistent  recognition  of  the  point  at  which  specialist  DN  support  and  advice  should  be 
sought.  There is open communication between the DN Service and the GPs for when advice 
is needed but in order to strengthen awareness the Masterclass referred to above will include 
DN advice around timely referral. 

Our Masterclass sessions are recorded and it would be our intention to record this planned 
session so that our wider NHS colleagues can also access the advice and guidance provided. 

(4) 

The  evidence  before  the  inquest  was  that  there  were  multiple 
specialisms across multiple GM Trusts with different IT systems involved in 
Mr Smith’s care. As a consequence communication was poor with a limited 
understanding of his overall condition and fragmented input. The inquest 
was told that a framework that promoted a structure for a multi-disciplinary 
team  approach  across  trusts  in  GM  would  avoid  many  of  the  challenges 
around information sharing across trusts.  

There is a ‘joint’ care record that exists across Greater Manchester (the GM Care Record) 
which  holds  information  from  various  organisations  including  GP  Practices,  Acute  Trusts, 
Adult Social Care (Local Authority) and Mental Health Trusts.  Most clinicians have access to 
this  system  and  to  provide  an  indication  of  how  often  it  is  used,  in  February  2024,  708 
individual acute trust staff accessed records 12,715 times, viewing 8,243 patients.   

Whilst  data  tells  us  that  the  system  is  being  accessed  and  patient  information  being 
appropriately  shared  via  the  GM  Care  Record,  it  is  acknowledged  that  not  all  health  care 
professionals  are  accessing  the  benefits  of  this  system.  With  this  in  mind,  there  is  a 
programme of work currently underway with a plan to update the web page and re-launch 
the GM Care Record in early June 2024.  The re-launch aims to raise awareness further and 
I can confirm that eLearning has been updated in addition to which additional training will 
be provided on how to access and use the system.   

I have included below links to additional information about the GM Care Record which I hope 
will be helpful to you:- 

•  www.gmwearebettertogether.com (public facing information) 
•  www.gmwearebettertogether.com/training (training information) 
•  The  GM  Care  Record  -  Health  Innovation  Manchester  (info  for  health  &  social  care 

teams ) 

In  circumstances  where  a  patient  is  being  cared  for  across  multiple  specialist  areas, 
information  is  shared  within  the  GM  Care  Record,  which  supports  but  is  not  intended  to 
replace a face to face MDT process where the overall care of a patient can be discussed.  
Technology  such  as  Microsoft  Teams  enables  representatives  in  multiple  organisations, 

                                                                                                                                               
 
 
 
 
 
 
 
 
 
 regardless of location (not just within GM), to ‘meet’ to discuss individual patients and this is 
a process that happens regularly. 

(5) 

In Mr Smith’s case there had been advice from secondary care to his 
GP  that  he  should  be  referred  on  the  2  Week  wait  path  for  dermatology. 
That  advice  was  not  taken  by  his  GP  who  felt  such  a  referral  was  not 
necessary. It was unclear what if any protocol was in place across GM when 
such advice was given but not followed  

The standard protocol for onward referrals from secondary care  (Stepping Hill Hospital) is 
that if a secondary care provider considers that an urgent referral onto a two week wait care 
pathway is required, then the referral should be completed by the secondary care clinician.  
This is because of the additional time involved in sending a recommendation into primary 
care and the referral then being completed.   

In circumstances where a routine referral is thought appropriate, and where this is directly 
related  to  the  presenting  condition  then  secondary  care  should  process  that  referral.  
However, if this is not the case then it would be appropriate for the referral to be passed 
back to the primary care provider for their action.   

In regard to a GP making a decision not to follow the advice of a secondary care colleague, 
the GP would always be responsible for their clinical decision making.  It would be unusual 
to ignore advice from a colleague without clinical justification.  In this case, my understanding 
is that Mr Smith was scheduled to imminently attend for a scan and the GP decision was 
therefore  to  await  scan  findings  prior  to  progressing  the  request  to  process  this  referral.  
From a clinical perspective this would be appropriate and in the interest of the patient. 

I hope the above information is helpful to you and that you are satisfied that steps are been 
taken  to  ensure  wider  learning  from  this  case  and  to  promote  improved  communication 
between services. 

Yours sincerely  

Chief Executive and Place Based Lead