Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0162, written 22 Mar 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 22 Mar 2024 |
|---|---|
| Reference | 2024-0162 |
| Deceased | Finlay Finlayson |
| Coroner | Laura Bradford |
| Coroner area | East Sussex |
| Category | Other related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: REPORT TO PREVENT FUTURE DEATHS NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: 1 The Phoenix Partnership 2 EMIS Health 1 CORONER I am Laura BRADFORD, Assistant Coroner for the coroner area of East Sussex 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 04 February 2019 I commenced an investigation into the death of Finlay Stuart Ian FINLAYSON aged 54. The investigation concluded at the end of the inquest on 19 March 2024. The conclusion of the jury was that: Narrative: we the jury consider that Vinney's care was affected by the following issues, the absence of which may have delayed or changed the circumstances of his death. There was confusion and uncertainty about his medical conditions caused by information sharing and permissions issues with SystmOne, leading to an over reliance on Vinney's own statements. Some poor record keeping on SystmOne and confusion over when to reference the system. This affected both plans and reporting of interactions. Failures in communication between agencies and shifts, not helped by the numbers of different staff and agencies involved, high demand and challenging workloads and associated delays in accessing healthcare. This was particularly relevant between 21 and 24 January 19. In particular we note: a lack of quantifiable evidence, e.g. NEWS scores or notes of proportionate follow-ups and recorded observations between 21 and 24/1/19 which may have allowed any deterioration in Vinney's condition to be missed. On 25/1/19, there was a grave and unacceptable failure in communications with two or three emergency radios switched off in contravention of prison rules and protocols. This was then compounded by a delay in timely response, i.e. the proposal of a phone call rather than an in-person response, which may have been longer had it not been for decisive intervention from comms. This was followed by unacceptable indecision on calling an ambulance, in which perceptions of Vinney's mental health were a factor, and should have been automatic on account of his head injury. 4 CIRCUMSTANCES OF THE DEATH Vinney died of the causes in section 2 (pulmonary thromboemboli due to deep vein thrombosis with a background of metastatic carcinoma of the base of the tongue) following cardiac arrest on 25/1/2019 at HMP Lewes (Cell 216 on C-Wing), whilst on remand. He was pronounced dead at 9.16am. 5 CORONER’S CONCERNS During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: Regulation 28 – After Inquest Document Template Updated 30/07/2021 (brief summary of matters of concern) During the course of the Inquest the jury heard evidence about the difficulty in information being transferred over from Mr Finlayson's GP surgery system, which uses SystmOne to the prison system (also SystmOne). The evidence was that information was not able to be freely shared between the two and it meant that there was a delay in healthcare staff in the prison accessing relevant information about Mr Finlayson's long term health issues as well to prision. as contact with his GP as recent as a week before going in Mr Finlayson sadly died in 2019 and I have heard evidence that the functioning of SystmOne has improved since his death. I was told, however, that there remains an issue with the interaction between SystmOne and other medical databases used in England and Wales. SystmOne appears to be the preferred system for many prisons and detention systems. centres but that use other still many GP there are surgeries I heard evidence that if someone goes to prison and is linked to a surgery that uses another system (like EMIS) the notes have to be printed and scanned on to SystmOne and hand. key information someone's record input onto has be by to I am concerned about the potential delay this process could cause. I am also concerned that key information could be missed by virtue of these systems not communicating with each other. I have heard evidence as to the importance of someone's medical history being available for those within the prison setting to assist with careplanning and the provision of appropriate care and in my opinion, there is a risk that future deaths could occur unless action is taken to make the transfer of this information more efficient. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) 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 May 17, 2024. 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 Mr Finlayson’s family HMP LEWES Sussex Partnership NHS Foundation Trust Med-Co Secure Healthcare Services Ltd I have also sent it to NHS England Practice Plus Group who may find it useful or of interest. I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any person who I believe may find it useful or Regulation 28 – After Inquest Document Template Updated 30/07/2021 of interest. 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 Dated: 22/03/2024 Laura BRADFORD Assistant Coroner for East Sussex Regulation 28 – After Inquest Document Template Updated 30/07/2021
2 responses 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.
Fulford Grange Micklefield Lane Rawdon Leeds LS19 6BA emishealth.com FAO Laura Bradford, Assistant Coroner for East Sussex Coroner’s Office (East Sussex), Unit 56, Innovation Centre, Highfield Drive, St Leonards on Sea, East Sussex, TN38 9UH 16th May 2024 Ref: Regulation 28 Report Dear Ms Bradford, We write in response to the Regulation 28 report, dated 22/03/2024 (the “Report”). We were saddened to read of the death of Mr Finlayson and would like to take this opportunity to express our sincere condolences to his family. We have undertaken an internal review of EMIS Web, focussing on the issues raised as areas of concern in the Report in relation to EMIS Web, namely a potential lack of interaction between clinical systems in prisons (predominantly SystmOne) and other clinical systems in community GP surgeries, and the evidence you heard that notes have to be printed and scanned on to SystemOne, with key information inputted manually, if an individual’s GP practice uses a clinical system other than SystmOne. This review was undertaken by our internal team, including a Product Manager, Clinical Safety Officer, and Clinical Director. Transfer of Medical Records In 2019, processes for transferring medical records from community GP practices to the relevant healthcare teams within prisons were aligned with the NHS England specification for Primary Care Service – Medical and nursing for prisons (latest PDF copy attached). At this time, we understand that GP2GP (an interoperability function that enables electronic transfer of medical records between clinical systems, introduced by NHS Digital (now NHS England) in 2007) was not integrated into the prisons’ clinical record systems, which meant that EMIS was unable to utilise GP2GP for medical record transfers. Therefore, EMIS advised sending printed medical records EMIS Health is a trading name used by members of the EMIS Group of companies which includes Egton Medical Information Systems Limited. Egton Medical Information Systems Limited is registered in England and Wales. Registered number: 02117205. Registered office: Fulford Grange, Micklefield Lane, Rawdon, Leeds LS19 6BA Fulford Grange Micklefield Lane Rawdon Leeds LS19 6BA Tel: 0113 380 3000 emishealth.com via courier, in line with the process adopted by Primary Care Support England, who were responsible for moving medical records around the NHS. With the implementation of GP2GP in prisons’ clinical record systems in 2021, medical records could then be transferred electronically from the relevant community GP practice, utilising any system provider, to prisons via GP2GP. Prisons require a GP Organisation (ODS) code to use the GP2GP service, as the ODS code determines where the request is sent and where the medical record is received. Once a patient has registered to a prison’s healthcare system, a 'GP2GP EHR Extract Request' is sent from the prison’s clinical system to the patient’s Community GP. The patient’s community GP can use EMIS Web to prepare the record and send it as a 'GP2GP EHR Extract' message. Once the prison receives and reviews the medical record, it is marked as ‘filed’ and the record should be integrated into the prison’s clinical system. The complete GP2GP process can be found in the GP registration digital guide here: www.digital.nhs.uk/services/guides/gp-registration. EMIS are fully compliant, and have processes in place to remain compliant, with the latest versions of the NHS England GP2GP specification. Therefore, EMIS practices can receive medical record requests from prisons and return the requested information via the GP2GP process. EMIS practices also have the option to send printed medical records via courier when medical requests are not received from prisons via GP2GP (at the prison’s discretion). In either scenario, EMIS would not have any control over whether the prison requests the medical records via the GP2GP process, or via a manual process. Conclusion We understand that the prisons and the clinical system providers involved have implemented the GP2GP process into prison systems since 2021, and as such, should a prison request medical records from a community GP practice utilising EMIS Web, there should be no reason why a transfer of medical records wouldn’t complete in an appropriate and timely manner (if the correct process for utilising GP2GP is followed). As detailed above, EMIS is compliant with NHS England GP2GP specifications, and we will continue to review our solutions to determine whether any performance improvements can be made. However, based on the information provided in the Report, and our subsequent review, we do not believe in this instance there are any software developments, beyond the existing functionality in the System, that are required to mitigate the specific risks raised in the Report. EMIS Health is a trading name used by members of the EMIS Group of companies which includes Egton Medical Information Systems Limited. Egton Medical Information Systems Limited is registered in England and Wales. Registered number: 02117205. Registered office: Fulford Grange, Micklefield Lane, Rawdon, Leeds LS19 6BA Fulford Grange Micklefield Lane Rawdon Leeds LS19 6BA Tel: 0113 380 3000 emishealth.com When needed, EMIS Web users have access to learning / training materials, including those materials regarding GP2GP, should they need to revisit how to prepare and send medical records to other healthcare facilities. Users are also able to contact EMIS support for any further guidance. Thank you for bringing this to our attention, and we trust that the details outlined above assist. Kind regards, Chief Medical Officer EMIS Health is a trading name used by members of the EMIS Group of companies which includes Egton Medical Information Systems Limited. Egton Medical Information Systems Limited is registered in England and Wales. Registered number: 02117205. Registered office: Fulford Grange, Micklefield Lane, Rawdon, Leeds LS19 6BA
Mrs Laura Bradford Assistant Coroner East Sussex Thursday, 28 March 2024 Dear Ms Bradford Regulation 28 report regarding Finlay Stuart Ian FINLAYSON Thank you for your Regulation 28 report dated 22 March 2024 concerning the death of Finlay Stuart Ian Finlayson on 25 January 2019. Firstly, I would like to express my deep condolences to the family and friends of Mr Finlayson on his tragic death. Your report addresses the sharing of patient information between healthcare providers in the NHS. This is a complex area. SystmOne was created 25 years ago specifically to support the provision of a shared electronic health record for the patient wherever they were receiving care, initially between GPs, an out of hours service and the local hospital, in Keighley, West Yorkshire. The system is now in use in multiple other healthcare settings across the country and is the national system for the detained estate in England and Wales. Your report highlights that information was not freely shared between the GP (using SystmOne) and the prison service. Functionality to allow seamless sharing of data is available within SystmOne, and this functionality was available to the detained estate (including prisons) from well before 2019. However, as is still the case, the sharing of data is dependent on the data controller (in this case the GP) permitting the data to be made available to other healthcare organisations. This responsibility is set out in UK Data Protection Legislation. Without the control in SystmOne being turned on by the GP data controller (and a reciprocal control on the receiving side being enabled) the data is not visible. Dame Fiona Caldicott and other data champions have tried to make information sharing ‘the norm’ but there is still resistance in many areas. If the controls that exist within SystmOne to facilitate data sharing had been enabled, Mr Finlayson’s entire SystmOne GP record would have been available to the prison service. Since the time of Mr Finlayson’s death, more has been done to improve matters. Full GP registration (‘GMS’) has been introduced into prisons in the last two years as a result of policy change by NHS England. Functionality was enabled by TPP to enact this policy change. As a result, prisoners can now opt to have their community GP registration (and their community GP record) transferred to the prison GP. This involves the automatic electronic transfer of the full community GP record to the prison GP, which is then transferred out again on release of the prisoner to the community GP practice. This is an enormous improvement. This change applies regardless of whether the community GP practice uses SystmOne or EMIS. If you require any further information please let me know. I would be happy to demonstrate the processes described if at all helpful. Yours sincerely Clinical Director TPP GMC 2672881
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