Michael Huggon

Carlisle Healthcare, Locke Road, Carlisle, CA1 3UB 
 01228 588121 
www.carlislehealthcare.co.uk 

Private and Confidential 

Dr Nicholas Shaw 
HM Assistant Coroner for Cumbria 
Fairfield 
Cockermouth 
CA13 9PT 

Sent via email: 

Dear Dr Shaw 

13th August 2024 

Re: Death of Michael Huggon – Regulation 28 Notice 

Thank  you  for  raising  the  matters  of  concern  further  to  the  investigation  into  the  death  of 
Michael Huggon. 

We have had an opportunity to reflect on the circumstances of the death as a practice, and 
have also met with colleagues from Cumbria Health (formerly Cumbria Health on Call). We 
enclose our response below. 

We  have  identified  a  number  of  themes  including  patient  access,  clinical  capacity,  patient 
safety  and  safe  working  practices,  cross  organisational  working  and  human  factors,  which 
help structure our response. 

Patient Access 

Patient access to general practice services has been increasingly challenging in recent years 
with  patient  demand  typically  exceeding  clinical  capacity.  In  response  to  increasing  patient 
demand  and  to  try  to  operate  safely,  many  practices,  including  Carlisle  Healthcare  had 
implemented  a  system  focussing  on  same  day  access  advising  a  patient  to  contact  the 
practice from 8am to request a same day appointment. Once daily capacity was exceeded 
patients  would  be  asked  to  “call  back  tomorrow”,  unless  the  request  was  “urgent”  in  which 
case  it  would  be  triaged  by  a  “duty  doctor”.  This  system  protected  same  day  access  to  a 
degree, but significantly limited the ability to book ahead for non-urgent problems. The process 
led to a high number of people being asked to contact the practice again the following day. 
This did not provide a good experience of “making an appointment” and fuelled an “8am rush 
in the competition to get an appointment. It also disadvantaged people with non-urgent health 
problems.  

From  April  2023  NHS  England  instructed  General  Medical  Practices  to  implement  an 
“assessment of patient need” when a patient contacts the practice in person, on-line or via 
telephone. .This is illustrated in figure 1 overleaf. 

 
 
   
 
 
 
 
 
 
 
 
 
 Figure 1 – Modern General Practice Access Model 1 

Carlisle Healthcare implemented “Modern General Practice Access” in June 2023. This aimed 
to  improve  patient  experience  of contacting  the  surgery,  see  and  understand  all  expressed 
patient  demand (removing the  need  to  “call  back  tomorrow”),  and  respond  to that  need (to 
offer the right care with the most appropriate clinician or service in a safe time frame). 

Approximately  70%  of  our  current  demand  comes  into  the  practice  online  via  an  approved 
third  party  provider  “eConsult”2.  The  remainder  of  our  patient  requests  are  taken  over  the 
telephone or face to face via our receptions desks. 

At Carlisle Healthcare, when a patient requests an appointment in person or on the phone, 
the trained call handler will ask the patient a series of structured questions to better understand 
the  nature  and  urgency of  the  request. This request  is  passed  to  a  central  care  navigation 
team within the practice. Each clinical request is viewed by a GP and a decision is made about 
the  disposition  of  the  request.  This  may  include  the  offer  of  a  face  to  face  or  telephone 
consultation within a specific time frame, signposting or referral to another appropriate service, 
or resolution of the case (e.g prescription or information issued). Some cases will be added to 
an urgent GP worklist for further clinical assessment/triage (e.g visit requests, or when there 
is  lack  of  clarity  from  the  original  submission).  Carlisle  Healthcare  receive  about  600 
appointment requests on a Monday and approximately 450 requests each day from Tuesday 
to Friday. 

In  general,  implementation  of  Modern  General  Practice  Access  has  been  a  positive 
experience. We no longer ask people to “call back tomorrow from 8am”. Patient experience 
has  been  positive  with  our  June  2024  Friends  and  Family  Test  score  currently  at  93% 
satisfaction.  

1 https://www.england.nhs.uk/gp/national-general-practice-improvement-programme/modern-general-
practice-model/ 
2 https://econsult.net/ 

 
 
 
 
 
 
 
 
 
                                                      
 Clinical Capacity 

Workforce  in  general  practice  continues  to  change.  There  are  now  fewer  GPs,  a  growing 
population, with an increasing number of people living longer lives with more complex health 
needs. 

Carlisle Healthcare has a registered patient population of approx. 38,500 people. We have 6.6 
whole time equivalent GP Partners and employ a further 9.6 whole time equivalent general 
medical practitioners. This equates to 0.4 whole time equivalent general practitioners per 1000 
registered patients. This is in keeping with England average. Local and national trends show 
an increasing number of patients per whole time equivalent GP year on year. 

We employ a wide range of health and care professionals within our general medical practice 
including nurses, health care assistants, care co-ordinators, advanced clinical practitioners, 
paramedic practitioners, social prescribing link worker, clinical pharmacists, physiotherapist, 
occupational  therapist,  mental  health  workers,  and  children  and  young  people’s  social 
prescribers.  Some  of these roles  are  supported by  ring fenced  and  pre-defined  NHS funds 
supported by the NHS England Primary Care Network Directed Enhanced Service. 3 

We provide a number of functions within general practice and organise ourselves in teams 
fulfil these. They include preventative care, (immunisation campaigns, cancer screening and 
health checks), enhanced health in care homes, planned proactive care for people with long 
term health conditions and complex care needs, acute visiting and personalised proactive care 
for people living with frailty. 

We strive to offer the capacity that we need to deliver a high quality service, but recognise that 
this often falls short. These workforce challenges are reflected nationally and are impacted by 
national policy. 

Patient Safety and Safe Working Practices 

The British Medical Association has published guidance for safe working in general practice.4 
The BMA recommends no more than 25 substantive patient contacts per GP per day for a GP 
to deliver safe care. Whilst recognising the BMA guidance, we have not implemented this at 
Carlisle  Healthcare  as  it  would  restrict  patient  access  and  add  additional  pressure  to  our 
already overstretched health and care partners. Despite this, we try to support our clinicians 
to work safely but recognise that they frequently go above and beyond their contracted working 
hours. 

Approximately 2% of the population contact their general practice on a daily basis.  

It’s  important  to  appreciate  that  general  practice  is  not  an  “emergency  service”.  We  work 
closely with partners to ensure that when people contact us they get the care that they need 
(e.g. directing a patient with a suspected heart attack to 999). We have safeguards in place to 
screen for life threatening and emergency conditions when people contact the surgery to be 
able to direct them to the most appropriate service.  

3 https://www.england.nhs.uk/gp/expanding-our-workforce/ 
4 https://www.bma.org.uk/advice-and-support/gp-practices/managing-workload/safe-working-in-general-
practice 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
                                                       
 Cross Organisational Working 

As a general practice we work closely with other health and care partners including Cumbria 
Health (out of hours), North Cumbria Integrated Care (acute and community services), Adult 
Social  Care,  Cumbria,  Northumbria,  Tyne  &  Wear  Foundation  Trust  (mental  health  and 
learning disability), North West Ambulance Service and a variety of voluntary, community and 
social enterprise organisations. 

Carlisle Healthcare provides core hours between 8am and 6.30pm Monday to Friday. Cumbria 
Health provides out of hours services via 111 when we are closed. 

Some work will naturally flow between out of hours and in-hours services as one service closes 
and another opens. Requests for follow up from out of hours cases to in hours services are 
messaged  electronically  to  the  patient’s  practice  for  further  action.  There  is  currently  no 
consistent  agreed  pathway  for  the  transfer  of  same  day  work  from  in-hours  providers  to 
Cumbria Health. 

Human Factors 

The initial request for a home visit for Mr Huggon was taken over the phone by one of our call 
handling  staff  at  2.15pm  on  6th  February.  This  request  was  passed  to  our  care  navigation 
team.  Unfortunately  a  clinical  decision  to  contact  the  patient  to  ascertain  more  information 
wasn’t made until 4.50pm and Mrs Huggon was contacted by a GP at 6.06pm that day, when 
a  home  visit  was  agreed  but  there  was  no  clinical  capacity  to  respond  directly  within  core 
working hours. The home visit was completed by the out of hours service later that evening. 

It  is  regrettable  that  it  took  over  two  hours  to  make  a  decision  for  a  clinician  to  phone  the 
patient to ascertain more details. This was in part due to the volume of work presented to the 
clinician that afternoon 

It is also regrettable that once a decision had been made, it took a delay of a further hour or 
so before the patient was contacted by phone. Again workload contributed to this delay. 

Our Response and Action Taken 

We  recognise  that  our  response  to  the  visit  request  was  not  adequate.  Clinical  capacity, 
workload and human factors played their part in this. 

Following  internal  discussion  within  Carlisle  Healthcare  we  have  agreed  to  implement  a 
performance indicator that all requests for acute home visits will be triaged by a clinician within 
60 minutes.  

Following discussion with Cumbria Health, we have agreed that any cases that have already 
been triaged and need same day clinical input after we have closed will be passed directly to 
Cumbria  Health  via  telephone,  instead  of  asking  the  patient  to  contact  111.  This  should 
improve the patient experience of care and reduce delay in response times. 

Both of these changes will be put in place with immediate effect. 

Clinical Director 
Carlisle Healthcare

Our Ref: 
Coroner Case Ref: 
CH Case: 

21 August 2024 

Dear Dr Shaw 

Prevention of Future Deaths Regulation 28 

Thank  you  for  raising  the  matters  of  concern  further  to  the  investigation  into  the  death  of 
Michael Huggon.  

Cumbria Health has reviewed the case and reflected on the findings you have highlighted. As 
part of this review, we met with our colleagues from Carlisle Healthcare on the 14 August. 

Our response is as below, and I have outlined them in two separate headings. 

1.  The systems in place currently 

Cumbria Health has for many years had processes in place to allow the exchange of clinical 
information  between  organisations  that  include  not  only  daytime  primary  care  but  other 
organisations such as community nurses, hospice, and secondary care. We are very aware 
that communication issues are often the cause of situations where things could have gone 
better for patients and the measures, we already have in place are there to mitigate this risk. 
We also fully recognise the pressures on daytime practice which include capacity to address 
all  the  patient  queries  that  arrive  at  the  practice  before  the  18.30pm  handover  to  Cumbria 
Health. 

Currently we have in place: 

•  A dedicated number for health care professionals to contact Cumbria Health after the 
surgeries  have  closed  (03000).  This  allows  a  clinician-to-clinician  handover  if 
necessary or a clinician to our “controller” to take the appropriate details and log onto 
the out of Hours patient system. 

•  A dedicated number (0300) that vulnerable patients have as part of their care package 
which allows then to contact Cumbria Health directly rather than go through NHS 111 
e.g. palliative care patients. 

•  A special patient note template that can be completed by the practice and electronically 

gets uploaded in the patients Adastra record.   

•  E-mail  inbox  (choc.north)  that  allows  transfer  of  information  from  practices  to  our 

control centre that is staffed 24/7. 

•  The control centre is staffed 24/7 anyway for any queries which could include passing 

over clinical cases of need at shoulder time in particular. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 2.  Action from the Regulation 28 request 

•  As discussed above, Cumbria Health has met with Carlisle Healthcare and completed 

a review of Mr Huggon’s case. 

•  The  case  will  be  discussed  at  our  regular  clinical  forum  with  the  emphasis  on 
assessing  capacity  when  patients  decline  an  admission  which  was  pertinent  to  Mr 
Huggon’s case but applies to any patient who declines or refuses treatment.  

•  We will put on educational sessions to update our clinicians on the mental capacity 
act,  managing  challenging  scenarios  with  particular  emphasis  on  how  this  is 
documented in a patient record (which is again pertinent to the case of Mr Huggon) 
•  We will ensure that the information in the section above is communicated to the GP 
practices through all of Cumbria on the options Cumbria Health has for discussing and 
handing  over  cases  of  concern  if  they  are  unable  to  manage  them  within  the 
constraints of their capacity, particularly at that shoulder time period of when they close 
and the Cumbria Health opens. This will be achieved by a standalone communication 
and guidance will be entered onto our newly developed website for ease of access.  

After meeting  with CHC I  know  that  they  have  put  in  place  some changes to the  way  they 
manage cases such as Mr Huggon and with our plan above to cascade the options we have 
in place to all practices. I hope the Coroner has gained assurance that the process are as 
robust as possible to prevent such cases as Mr Huggon’s from happening in the future. 

Yours sincerely 

Medical Director