Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0468, written 23 Aug 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 23 Aug 2024 |
|---|---|
| Reference | 2024-0468 |
| Deceased | Allan Hamilton |
| Coroner | Alison Mutch |
| Coroner area | Manchester South |
| Category | Community health care and emergency services 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 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1)SSP Health 2) Department of Health and Social Care 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 20th November 2023 I commenced an investigation into the death of Allan Robin Hamilton. The investigation concluded on the 16th July 2024 and the conclusion was one of Narrative: Died from Lobar pneumonia after a request for advice from his GP practice was not actioned until 3 days after it was sent to them. The medical cause of death was 1a) Lobar Pneumonia II) Ischaemic Heart Disease 4 CIRCUMSTANCES OF THE DEATH Allan Robin Hamilton sent an email to his GP practice on 14th November 2023 indicating he was having breathing difficulties and seeking advice. The email was not responded to until 17th November when he was sent an email asking if he still needed an appointment. On 19th November 2023 he was found unresponsive at his home address. A Postmortem examination found he had died as a consequence of lobar pneumonia. On the balance of probabilities, he would not have died on the day he did had he seen a doctor on 14th November 2023. 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. – The inquest heard evidence that the GP practice in question is owned by SSP Health. The company owns a number of GP practices and that operate on a similar model. Like many GP practices the surgery in question had moved to a system where contact was encouraged electronically. The surgery had no system for tracking email queries such as the one sent by Mr Hamilton and there was no clear system for triage of emails such as the one he sent. The inquest heard evidence that an electronic system of patient referrals is only effective if there is a clear and robust process for checking regularly for patient contacts, a clear audit trail and effective triage by medically qualified members of the team. 1 In Mr Hamilton’s case effective scrutiny of his query and follow up contact from his GP on 14/11 and medical advice would probably have meant he would not have died when he did. The inquest heard evidence that there was a risk of a similar situation arising if GP practices do not have clear and robust triage and audit processes in place. ACTION SHOULD BE TAKEN 6 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 18th October 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 namely on behalf of the family, who may find it useful or of interest. 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 23/08/2024 2
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.
Our ref: HM Coroner Alison Mutch 1 Mount Tabor Street Stockport SK1 3AG By email: Dear Ms Mutch Minister of State for Care 39 Victoria Street London SW1H 0EU 08 October 2024 Thank you for the Regulation 28 report of 23rd August sent to the Department of Health and Social Care about the death of Mr Allan Robin Hamilton. I am replying as the Minister of State for Care, responsible for primary care and general practice. Firstly, I would like to say how saddened I was to read of the circumstances of Mr Hamilton’s death and I offer my sincere condolences to his family and loved ones. The circumstances your report describes are concerning and I am grateful to you for bringing these matters to my attention. The report raises concerns over the lack of robust processes or systems practices may have when they are accepting online requests through their online consultation systems. In preparing this response, Departmental officials have made enquiries with NHS England and the Care Quality Commission to ensure we adequately address your concerns. Use of digital channels in general practice The Department, NHS England, and practices alike must be cognizant of the fact that there are now multiple channels by which a patient may contact a GP practice. This includes by direct face to face contact at a surgery, by telephone, by customised online systems or by email. While more options have opened up more opportunities for patients to access care they need, we understand that it may also open up more opportunity for patients to slip through the cracks, which is unacceptable. We want to make sure that patients are able to easily access primary care and that it is not a complex system that inevitably makes it harder for patients to access. I am deeply upset that this patient was unable to access care before he sadly passed away. We need to do better, so patients can receive the care they deserve. General practices are independent businesses who are contracted by NHS commissioners to perform medical services, and as a result it is the responsibility of the individual practice (provider) to have reliable systems in place to manage interactions with patients. If a A4 practice felt unable to monitor a general email address in a timely way to detect clinical concerns raised, then a system should be in place to manage this. We recognise that practices need adequate support to be able to put these systems and pathways into place, and NHS England produced guidance on this in May 2024. The guidance supports practices in care navigation and includes a key principle that clinical requests not allocated by care navigation (i.e. over the phone or via online consultation systems) need to come into a single flow for assessment. This is to reduce risks of patient requests being missed. The document, however, does not contain the specifics of managing email correspondence and signposting patients to an appropriate channel. This is because, as independent businesses, practices are ultimately responsible for the daily operations of their business outside of their contractual obligations which includes how they manage their email correspondence. They do this to appropriately tailor it to their own requirements and patient cohorts, as they know their local needs best. The GP contract requires practices to provide an appropriate response to patients on the day the patient contacts the practice (or the next day if they contact the practice in the afternoon), according to the urgency of their clinical needs and other circumstances. This includes patients contacting the practice electronically. An appropriate response could include inviting the patient to an appointment either in person or over the phone, providing advice or care by another method, signposting the patient to other services, or communicating with the patient to request more information. Following contact made by a patient the practice must manage the presenting complaint in a safe and timely way in line with the Health and Social Care Act 2008 Regulations 2014: Regulation 12 (Safe care and treatment). The intention of this regulation is to prevent people from receiving unsafe care and treatment and prevent avoidable harm or risk of harm. The CQC expects those working within a service to have the knowledge and skills to use the systems in place, and for there to be sufficient numbers of staff with the right skills employed to meet the needs of those using the service. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2008 requires providers to provide patients with information about their care and treatment options, which the CQC expects to include information on how to access care and treatment. The CQC assesses access to services, including GP practices, through their single assessment framework under the “Responsive” key line of enquiry. The equity in access Quality Statement allows the CQC to assess whether people accessing services can so do in a timely manner that is in line with best practice. Local response I understand that NHS Greater Manchester ICB will be working closely with the practice and SSP Health as an organisation to ensure that digitised services within general practice are safe and meet required national standards: specifically, the standards DCB0129 and DCB0160, which relate specifically to clinical safety and are published under Section 250 of the Health and Social Care Act 2012. The ICB will also be looking at any wider work that is needed across the NHS Greater Manchester system in relation to this issue. SSP Health is also in the process of preparing a separate response to this report. A5 I hope this response is helpful. Thank you for bringing these concerns to my attention. Yours sincerely, A6
SSP Response to Regulation 28 REGULATION 28: REPORT TO PREVENT FUTURE DEATHS This report details the steps taken by The Pike Practice following the death of Mr Allan Robin Hamilton who died of lobar pneumonia after a request for advice from his GP practice via email. It is important to note that at no point has The Pike Practice informed patients not to contact the practice by phone or encouraged the use of email. We do offer an online system which patients can chose to use should they wish. We have robust and clearly defined triage system for both calls and the online system. The practice does not expect or anticipate the use of emails as a means of making the practice aware of any medical issues – particularly anything serious. The emergency services (999 and even 111) are there for serious issues which is well known by the general patient population. This set-up is consistent with most GP surgeries in the UK. The coroner’s report should be amended to reflect these facts. In the context of it being widely recognised that emails are not for medical use, The Pike Practice, along with all SSP practices, has a structured system for managing emails. Each email is read, reviewed, and directed to the appropriate staff member. While this process was in place and adhered to at the time of the incident, the email in question was not read within the usual 48-hour window, resulting in a delay of 24 hours beyond our usual internal standard timeframe. Our automated email response informs patients that this inbox is intended for non-urgent inquiries, such as prescription requests and general queries. The patient would have seen the following response on the 14th of November 2023: Thank you for your email, we aim to respond to you within 48 hours of receiving your query. If you have not received a response, please contact 01457 832561. For appointments, we ask that you use our online consultation form as per NHS Guidelines; it is a quick and easy process that is available 24/7. You can use this form through the Patient Access app or through our practice website https://www.ssphealth.com/our- practices/the-pike-practice . For medication, please be advised that it can take up to 48 hours for your prescription request to be actioned. We ask that you do not submit a request on the day you run out of your medication as we cannot guarantee this will be actioned on the same day. As an outcome, upon review, we have updated the automated response to clearly reinforce what is commonly understood, i.e. that emails are for non-urgent enquiries only and the emergency services should be contacted in such circumstances. Please see below, the updated automated response: THIS EMAIL SERVICE IS NOT FOR EMERGENCY OR IMMEDIATE RESPONSES FROM THE PRACTICE. ‘IMPORTANT’ – PLEASE CALL 999 IF YOU ARE EXPERIENCING SHORTNESS OF BREATH, CHEST PAIN OR OTHER SYMPTONS THAT MAY REQUIRE URGENT RESPONSE OR CARE THIS EMAIL MAY NOT BE SEEN BY ONE OF OUR STAFF IMMEDIATELY AND IS FOR NON-URGENT COMMUNICATIONS ONLY. Page 1 of 3 A1 SSP Response to Regulation 28 Thank you for your email, we aim to respond to you within 48 hours of receiving your query. If you have not received a response, please contact 01457 832561. For appointments, we ask that you use our online consultation form as per NHS Guidelines; it is a quick and easy process that is available 24/7. You can use this form through the Patient Access app or through our practice website https://www.ssphealth.com/our- practices/the-pike-practice . For medication, please be advised that it can take up to 48 hours for your prescription request to be actioned. We ask that you do not submit a request on the day you run out of your medication as we cannot guarantee this will be actioned on the same day. In addition to the steps already mentioned, a monthly compliance audit has been implemented as a preventative measure. This audit reviews email response times to ensure the process remains efficient, with the automated patient response system fully operational. Following the incident, the automated email response across all SSP practices was updated to stress the importance of seeking urgent medical attention for life-threatening or serious symptoms. The message now includes relatable examples, such as shortness of breath, to clearly guide patients on when to seek emergency care. It is crucial to highlight that the email system has never been used for patient triage. For this, we have long relied on AccuRx and Online Consultations, which have been in place for several years as our electronic triage systems. This set-up is widely used across most GP practices in the UK. The practice has robust and appropriate processes in place for managing emails. This was an isolated incident, which should have been directed, by the patient, to the emergency services (999 or 111) or, or as a minimum, a phone call to the practice. However, after a comprehensive investigation, a series of actions have been implemented or are in the process of being implemented: - Response to family members (Appendix A) - Timeline of events (Appendix B) - Action Log (Appendix C) - Update of Automated Email response across all SSP practices (Outlook item attached) - Audits of the Email response times over a six-month period, showing compliance of response times (Appendix E) - Governance Meeting Minutes (Appendix F) - SOPs (Appendix G) - The response to be added to all SSP practice websites. - Educational communications via social media practice accounts - Audit to highlight the automated email and audit of email responses to be a standing process across SSP Health - HR discussions with staff - Staff competency and updated by the practice manager. - Meetings with senior management to discuss. The deceased patient contacted the practice via email, which is clearly designated for non- urgent inquiries such as prescription requests and test results. At no point is email promoted Page 2 of 3 A2 SSP Response to Regulation 28 as a primary method of contact for emergencies. In fact, it is made clear that this is not the appropriate channel for urgent situations. All SSP practices, including The Pike Practice, have an automated email response in place that explicitly advises patients to dial 999 in case of an emergency. Please refer to the updated automated email response for details. In response to the incident, a comprehensive set of measures were implemented during the investigation in 2023, with these efforts continuing to date. We are committed to ongoing improvements to prevent a recurrence of this nature. Page 3 of 3 A3
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