Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0381, written 17 Jul 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 17 Jul 2024 |
|---|---|
| Reference | 2024-0381 |
| Deceased | David Almond |
| Coroner | Alison Mutch |
| Coroner area | Manchester South |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | East Cheshire NHS Trust |
| 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 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1)NHS England 2) East Cheshire NHS Trust 1 CORONER I am Alison Mutch, Senior Coroner, for the coroner area of South Manchester 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 8th January 2024 I commenced an investigation into the death of David Nicholas ALMOND. The investigation concluded on the 8th July 2024 and the conclusion was one of Narrative: Died from the complications of thrombophilia when he had not been placed on lifelong anticoagulants when he should have been. The medical cause of death was 1a) Massive pulmonary embolism 1b) Thrombophilia. 4 CIRCUMSTANCES OF THE DEATH David Nicholas Almond had a family history of deep vein thrombosis. He was diagnosed with thrombophilia in 2013. That information was in his GP records. On 7th September 2022 he was diagnosed with a deep vein thrombosis at Macclesfield District General Hospital and started on anticoagulant medication and referred to the deep vein thrombosis clinic. The notes indicate that thrombophilia and a family history of deep vein thrombosis were mentioned. On 21st September 2022 he had a telephone appointment with the deep vein thrombosis clinic. His family history and diagnosis of thrombophilia was not explored fully and he was not placed on lifetime anticoagulation. He should have been. On 25th September 2023 he complained of breathlessness on exertion. He was seen by an advanced nursing practitioner at his GP surgery. The possible risk of an embolism was not recognised and he was sent for an x ray which would not diagnose a pulmonary embolism. The x ray was clear. He was not seen again although the x ray excluded other potential causes of his breathlessness. On 3rd January 2024 he collapsed at his home address and was taken to Stepping Hill Hospital where a massive 1 pulmonary embolism was found. He deteriorated and died at Stepping Hill Hospital on 5th January 2024. 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 Macclesfield Hospital was part of East Cheshire NHS Trust and served a wide area a significant part of the area served was outside the footprint of the trust for example the High Peak in Derbyshire. The inquest was told that trust doctors were able to access GP records for patient’s registered with GPs in East Cheshire but not patients registered outside this area. The inquest was told there were discussions about how to try to resolve this but no firm steps or progress on this by the Trust. As a consequence doctors at the hospital were limited in understanding a patient’s history and crucial information was not always fully recognised/available. 2. The inquest was told that this inability to access information in GP records was a problem across the NHS due to differing IT systems and caused difficulties in providing effective and timely care to patients. 3. The inquest heard evidence that in September 2023 when he went to his GP practice he did not see a doctor. It was not recognised by the practitioner who saw him that there may need to be a follow-up appointment or a recommendation that he return to see a doctor should the x ray be negative given his history and presentation. 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 11th September 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 2 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 Healthcare, who may find it useful or of interest. on behalf of the family, GTD 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 17/07/2024 3
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.
Ref: Date: 03 September 2024 PRIVATE AND CONFIDENTIAL Ms Alison Mutch Senior Coroner Manchester South Coroner's Court 1 Mount Tabor Street Stockport SK1 3AG Office of the Medical Director Trust Headquarters, Top Floor New Alderley Building Macclesfield District General Hospital Victoria Road Macclesfield Cheshire SK10 3BL Tel: Email: www.eastcheshire.nhs.uk Follow us @eastcheshirenhs Dear Ms Mutch Re: Inquest into the death of Mr David Almond I write regarding the inquest into the death of Mr Almond which concluded on 8th July 2024 in which you issued a Regulation 28 Report to Prevent Future Deaths. May I take this opportunity to express our sincere condolences to the family of Mr Almond. I understand that the Regulation 28 Report was issued to East Cheshire NHS Trust on the basis that the Trust is not able to access GP records for patients who are outside the footprint of the Trust. We, the Trust understand that your concern is that limited information sharing causes difficulties in providing effective and timely care to patients and that this poses a risk that future deaths may occur. In collaboration with the medical teams in the Acute Medicine Department and the Digital Services Team, the Trust has carefully considered your conclusion. We have outlined below our response and the actions which the Trust will undertake to reduce the risk of further harm. For clarity these are presented below in three subsections: 1. The inability to access GP records for the wider footprint of East Cheshire NHS Trust. 2. The inability to access information in GP records due to differing IT systems across the NHS. 3. The inquest heard evidence that in September 2023 when he went to his GP practice, he did not see a doctor. It was not recognised by the practitioner who saw him that there may need to be a follow-up appointment or a recommendation that he return to see a doctor should the x-ray be negative given his history and presentation. We, the Trust, have addressed matter one in full. We have addressed matter two briefly, as we are aware this is being addressed in full by NHS England in their response. We have liaised with gtd healthcare to provide further information for matter three as this does not concern care provided by East Cheshire NHS Trust. Chair – Chief Executive – A4 1. The inability to access GP records for patients in the wider footprint of East Cheshire NHS Trust. The local, regional, and national infrastructure for sharing patient records is complex. A variety of digital systems are available, but it is a complex landscape arising from locality- focused legacy investments and collaborations. Although Integrated Care System (ICS)- based record sharing arrangements are progressing, significant challenges around how they are resourced remain, and a clear national architecture for sustainably linking together ICS-based shared records, and / or developing national infrastructure in this domain, remains in development. This complexity is heightened for a provider like East Cheshire NHS Trust with a catchment area spanning several ICS boundaries and a requirement to view patient records from across the catchment. That said, the following possibilities have been identified. The Summary Care Record On the 14th of August 2024, the Trust's Chief Information Officer met with the Integrated Care Board (ICB) Lead for Shared Records and the ICB Assistant Manager for Derbyshire. The purpose of the meeting was to discuss potential information-sharing solutions. As a result, the Summary Care Record (SCR) was identified as the most appropriate system for accessing external patient records. The SCR is a national database containing essential patient information, such as current medications, allergies, and any adverse reactions to medications. This information is derived from GP medical records and is accessible by authorised staff across various healthcare settings, including Accident & Emergency and acute assessment units. The SCR offers clinicians the advantage of accessing previous diagnoses and medication records, which is crucial for providing comprehensive patient care. By enabling access to the SCR, clinicians at East Cheshire NHS Trust would be able to view key details of GP records for patients registered outside the East Cheshire boundary, significantly improving the continuity of care. Implementation Plan To successfully implement SCR access, the following steps will be taken: 1. Identification of Relevant Staff The Trust will identify groups of staff who would benefit from access to the SCR. These groups have been provisionally identified as, Clinical staff in the Emergency the Discharge Team. Further Department, Medical Assessment Unit and assessments will ensure all necessary personnel are included. 2. Smart Card Distribution and Access Each staff member will require a smart card to access the SCR. A smart card is a plastic card containing an electronic chip and is used alongside a pin to provide staff with the appropriate level of access to the healthcare information. The Trust will ensure that all relevant staff have smart cards. Those who do not will be booked into a fast access smart card clinic where they can obtain one. A5 3. Training and IT Induction Staff will receive training on how to access and use the SCR. This training will be provided in a face to face format in the Trust lecture theatre or via Microsoft Teams, allowing staff to practice accessing the system during the session. Additionally, the Trust will design an IT induction program for new starters, focusing on SCR usage. 4. Super Users and Troubleshooting The Trust will establish departmental super users who will assist staff with queries, ensuring swift resolution of issues. A clear troubleshooting pathway will also be implemented, addressing common issues such as expired smart cards and incorrect permissions. 5. Implementation Timeline The Trust aims to roll out SCR access by the end of December 2024. Post-Implementation Review Following the implementation period, the Trust will conduct an audit to assess SCR usage and gather staff feedback for potential improvements. This review will include: 1. Incident Reporting System (Datix) A review of Datix will be conducted to identify any issues related to access to patient records. 2. Staff Usage Audit and Feedback An audit of staff usage of the SCR, supplemented by questionnaires to gather feedback. 3. NHS Midlands and Lancashire Commissioning Support Unit Data Review An analysis of data from the CSU on logged calls related to smart cards, identifying common issues, affected staff, and potential mitigation strategies. Further Mitigating Factors In response to this incident, the Trust has also taken proactive measures to enhance patient care and reduce the risk of recurrence by making changes to the Deep Vein Thrombosis (DVT) telephone follow-up clinics. Changes to DVT Telephone Follow-Up Clinics 1. Clinic Scheduling Adjustments • Reduced Frequency and Increased Capacity: The frequency of DVT follow-up clinics has been reduced, while the number of patients seen in each clinic has increased. This adjustment allows clinicians more time to prepare for each patient and consider specific questions tailored to individual needs. • Dedicated Post-Clinic Time: Additional time has been allocated after each clinic session to thoroughly complete any necessary follow-up actions, such as ordering further investigations, making referrals, and/or drafting complex communication letters. This ensures that all patient needs are addressed comprehensively. A6 2. Enhanced Patient Interaction and Assessment • Tailored Questioning: Clinicians now dedicate time before clinics to prepare personalised questions for each patient, enhancing the detail and relevance of assessments. For instance, younger patients are routinely asked about family history and past DVT incidents, which has already led to the early detection of a potential inherited thrombophilia in a young man. • Collaboration with GPs: In cases where patients are unable to provide detailed information, clinicians are encouraged to communicate directly with the patient’s GP. This ensures that all relevant medical history is obtained, supporting a more accurate and comprehensive assessment. 3. Improved Patient Communication and Safety Netting • Verbal and Written Advice: During the clinic, patients receive tailored safety netting advice, which is also included in the follow-up letter sent to both the patient and their GP. This advice is personalised to consider the patient's lifestyle, travel habits, and sports activities, ensuring that it is relevant and actionable. • Holistic Approach Dissemination: The additional time allocated before and after clinics allows clinicians to adopt a more holistic approach to patient care. This approach is being actively shared with junior doctors, promoting a consistent standard of care across the team. These changes aim to improve the quality of patient care by providing clinicians with the time and resources necessary to thoroughly evaluate each case, consider individual patient needs, and ensure that all follow-up actions are completed effectively. The doctor involved in this incident delivered an anonymised presentation of the facts and outcome of Mr Almond's unfortunate death at the Medical Department meeting on 16 August 2024. This has enabled a wider dissemination of the lessons from Mr Almond’s death and increased awareness of the changes that have been implemented. Individual Learning and Reflection The doctor involved in this incident has also undertaken extensive reflection on their role in Mr Almond’s care. During the inquest, the doctor acknowledged that the decision to discontinue anticoagulants was incorrect, given the information available at the time. Key Reflections and Changes in Practice • Acknowledgment of Error: The doctor openly accepted that had they been fully aware of all pertinent information during the clinic, they would have continued anticoagulation importance of the comprehensive information gathering in clinical decision-making. recognition underscores therapy. This • Commitment to Professional Curiosity: Moving forward, the doctor has committed to demonstrating greater professional curiosity. This includes proactively asking the GP to review older records when we do not have access to the relevant information, ensuring that decisions are based on the most complete information available. A7 • Personal Practice Changes: The doctor has made significant adjustments to their approach, particularly in gathering patient information. They now prioritise obtaining a more thorough understanding of each patient's history and context before making clinical decisions. • Contribution to Collective Learning: The doctor is using the insights gained from Mr Almond’s case to educate others. By sharing their reflections and the lessons learned, they aim to increase awareness and promote better practices among colleagues, thereby improving overall patient care. 2. The inability to access information in GP records due to differing IT systems across the NHS. As detailed in relation to matter one, the Trust is implementing the use of the Summary Care Record as a way for clinicians to gain further information. This would not only be beneficial for patients in the bordering areas of the Trust but will also be of benefit at a national level . The national Connecting Care Records program is currently reviewing its technical target architecture options, timescales, and associated resources. Details are expected to be made available as part of the emerging national One Digital strategy. It is anticipated that these future developments will aim to improve and simplify record sharing arrangements across the whole of the NHS. As well as technical enablers, it is anticipated that information governance arrangements will be streamlined, retaining vital controls and assurances but simplifying the administration of data sharing across boundaries for direct care purposes. The Trust understands that NHS England will be addressing this matter in detail within their response to the PFD and therefore proposes not to address this further. 3. The inquest heard evidence that in September 2023 when he went to his GP practice, he did not see a doctor. It was not recognised by the practitioner who saw him that there may need to be a follow-up appointment or a recommendation that he return to see a doctor should the x-ray be negative given his history and presentation. As this concern relates to Mr Almond’s clinical contact with his GP practice and not to care delivered by East Cheshire NHS Trust, we have sought the input of the gtd healthcare for the GP practice to provide the response that follows: It is established practice in primary care that care is delivered by a multi-disciplinary team. The team may include for example, GPs, advanced clinical practitioners (ACPs), pharmacists, practice nurses or healthcare assistants. ACPs have completed additional qualifications to Masters level that enables them to independently assess and manage a range of clinical presentations. As such, patients who are seen by an ACP do not have to be routinely seen by a GP either before or after their consultation with the ACP. However, as autonomous practitioners, if an ACP believes that the patient’s presenting complaint is outside their defined scope of practice to safely assess and manage, they can escalate to the onsite GP if an immediate review is required or re-book the patient into a GP appointment for a later date. A8 The types of caseloads that will be booked in to see ACPs will often be patients with acute or new undifferentiated presentations. Further information about what is expected of ACPs can be found in the following guidance: https://www.skillsforhealth.org.uk/services/item/724-advanced-clinical-practice-core- capabilities-for-nurses-working-within-general-practice-settings-in-england The care provided by the ACP has been reviewed and the Coroner's concerns noted. We agree that Mr Almond's family history and diagnosis of thrombophilia should have been documented by the ACP and explored fully with Mr Almond. The reasoning behind the decision to refer Mr Almond for a chest x-ray should have been documented by the ACP, as should have the reasoning for excluding a possible pulmonary embolism. The ACP's plan (as documented in the records) was that the x-ray results should be reviewed on receipt. What is not recorded, and should have been, is the advice Mr Almond should have received that if his symptoms did not resolve, worsened or returned when previously resolved, he should seek medical advice. It should also have been recorded that if his chest x-ray results were normal, further investigation might nevertheless be warranted. At the inquest the Coroner heard evidence that the following steps have been taken in response to this incident: • Additional learning regarding the identification and management of venous thromboembolism including the use of anticoagulation has been shared with all clinical staff. • Consultation with East Cheshire NHS Trust has taken place to enhance both parties' understanding of the DVT pathway and the information that is provided to patients about management of their risk of pulmonary embolism. Since the inquest, the following actions have also been identified: • Record keeping guidelines will be updated to give greater guidance on the need to document in the notes all relevant past medical history i.e. those elements relating to the presenting symptoms, and to also include a differential diagnosis or the rationale for excluding a potential diagnosis so that it is clear what has been taken into consideration when determining a management plan. • Opportunities for learning from the case will be shared as part of the organisation's clinical hot topics bulletin and as part of its Non-Medical Prescribers/ACP forums. The Trust is always keen to review, learn and wherever possible, strengthen our clinical processes and so we are grateful for your bringing these concerns to our attention. We hope the above offers you assurance of the Trust’s ongoing commitment to managing patient safety risks and continually improve the services we provide. Yours sincerely Medical Director A9
Ms Alison Mutch Senior Coroner Manchester South Coroner’s Court 1 Mount Tabor Street Stockport SK1 3AG National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG 9 September 2024 Dear Coroner, Re: Regulation 28 Report to Prevent Future Deaths – David Nicholas Almond who died on 5 January 2024. Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 17 July 2024 concerning the death of David Nicholas Almond on 5 January 2024. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to David’s family and loved ones. NHS England are keen to assure the family and the Coroner that the concerns raised about David’s care have been listened to and reflected upon. My response to your concerns focuses on those areas of concern that fall under the remit of national NHS England policy or programme work. Your concerns relating to East Cheshire NHS Trust’s recording sharing and access arrangements, along with your concerns about the care provided at the GP surgery, are more appropriately answered by the two organisations. The Standard General Medical Services (‘GMS’) Contract also sets out the requirements on GP Practices. Practices should provide enough appointments to meet the reasonable need of their patients, and provision of appointments and advice or care should consider their patients’ preferences where appropriate. NHS England have engaged with East Cheshire NHS Trust, who we note your Report is also addressed to, and NHS Cheshire and Merseyside Integrated Care Board (the responsible commissioner for the Trust) to discuss your concerns. We are aware that they are responding to the Coroner separately. Regarding your concern that there is an inability to access information in GP records across the NHS due to differing IT systems, there are various programmes of work to improve record-sharing where individuals are transferred between different care settings. The National Care Records Service (NCRS) is the successor to the Summary Care Record application (SCRa) and by design removes a large amount of the reported barriers to adoption within many care settings, including the private sector. The NCRS provides a quick, secure way for health and care workers to access national patient information, to improve clinical decision making and healthcare outcomes. It is free to use and includes additional features and services beyond the legacy SCRa product. It provides access to a number of centrally provisioned national digital services that A1 support the direct care of patients, including the Summary Care Record (SCR), the National Record Locator (NRL) service and the Personal Demographics Service (PDS). The SCR is a national database that holds electronic records of important patient information such as current medication, allergies and details of any previous bad reactions to medicines. It is created from GP medical records - whenever a GP record is updated, the changes are synchronised to SCR. It can be seen and used by authorised staff in other areas of the health and care system who are involved in the patient's direct care, but do not need access to the patient's full record. NHS England’s National Record Locator (NRL) service allows health or social care workers to find and access patient information shared by other health and social care organisations across England, to support the direct care of a patient. It does this by recording the location of digital (and paper) records within the NHS and it provides an index of pointers/bookmarks that contain the information required to retrieve key patient information from the source. Our vision is to improve cross-border interoperability and help make data sharing possible, by allowing healthcare professionals to securely and remotely retrieve information from source at the point of need, so that they can get a longitudinal view of a patient’s records and an indication of their treatment history. The NRL removes the need for organisations to create duplicate copies of information across systems and organisations, by facilitating access to up-to-date information directly from the source. Shared Care Records are another avenue by which healthcare professionals may access existing information about a patient. Shared Care Records join up information based on an individual rather than one organisation, and may include information such as test results, medications, outpatient appointments, inpatient stays and clinical contacts. It is our future ambition that Shared Care Records will enable authorised health and care staff from across England to access fully interoperable and comprehensive records for patients. Responsibility for delivering Shared Care Records sits with local Integrated Care Boards (ICBs). Each ICB’s Shared Care Records are developed in response to the health and care needs of the local area, existing systems, and future planning. This means some of their Shared Care Records are available to neighbouring ICBs, while others are only supported within their own ICB. Future plans include making Shared Care Records link together regardless of where you live or receive care in England. Further information on Integrated Care Boards and Systems can be found here: NHS England » What are integrated care systems? I would also like to provide further assurances on the national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around events, such as the sad death of David, are shared across the NHS at both a national and regional level and helps us to pay close attention to any emerging trends that may require further review and action. A2 Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information. Yours sincerely, National Medical Director A3
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