Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0559, written 17 Oct 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 Oct 2024 |
|---|---|
| Reference | 2024-0559 |
| Deceased | Leslie Swindells |
| Coroner | Alison Mutch |
| Coroner area | Manchester South |
| Category | Community health care and emergency services related deaths · Suicide (from 2015) · Mental Health 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) GTD Healthcare 2) Secretary of State for 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 7th June 2024 I commenced an investigation into the death of Leslie Andrew SWINDELLS .The investigation concluded on the 4th October 2024 and the conclusion was one of narrative: Died from the consequences of a self-inflicted puncture wound when his deteriorating mental health condition was not sufficiently recognised or acted upon within the primary care setting when he sought help. The medical cause of death was 1a) Exsanguination 1b) Transection of the right internal jugular vein 1c) Puncture wounds to the neck 4 CIRCUMSTANCES OF THE DEATH Leslie Andrew Swindells had a complex mental health background. He was prescribed olanzapine and venlafaxine for his mental health and had been stable within the community. In May 2024 he started to display symptoms consistent with his mental health deteriorating including symptoms of paranoia. His family contacted the GP practice on 21st May 2024 with their concerns. An appointment was made for 2 days later with a mental health assistant practitioner. He should have been offered a same day appointment or referred to the Emergency Department. On 23rd May 2024 he spoke to a mental health assistant practitioner who was not qualified to assess him or his needs. They lacked the expertise to deal with him. A referral was to be made to secondary care. It was not made. His deteriorating condition and the increased risk he presented was not recognised due to the lack of experience of the practitioner and steps to mitigate the risk were not taken. He was not given any safety netting advice, was not escalated to a GP to be seen that day, his suicidal ideation was not explored. He was told he would be contacted following a referral. His mental health continued to deteriorate and on 29th May 2021 1 he was found unresponsive at his home address self-inflicted puncture wounds to the neck. from 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 the practitioner who saw Mr Swindells had very limited training in mental health and was employed in a role described as a mental health assistant practitioner. The evidence was that there was limited understanding of the scope of their role by GPs and what was covered by the term routine mental health appointments. 2. In Mr Swindells case the evidence was that he should never have had a review undertaken by someone with such a limited an understanding of mental health and that lack of understanding of mental health meant that the practitioner did not recognise the level of risk Mr Swindells posed. 3. The appointment had been booked via the reception team with no triage by a doctor following a telephone call to the practice. The evidence was that a shortage of trained reception/admin staff meant that an agency worker was screening calls that day and had a limited understanding of how patients needed to be allocated. 4. The evidence was that where GP practices chose to deploy staff with such limited qualifications to see those who needed treatment for their mental health it was essential that all those in the practice understood the limitations of the role and that there was close supervision of the practitioner. 5. The inquest heard that it was envisaged by the practice that the GP on duty would have a supervisory role. However it was unclear how this operated other than by the mental health assistant escalating a concern to the duty GP. 6. The assessment was carried out by telephone. The inquest was told that approximately 80% of the practitioner’s mental health reviews took place in this way although it was accepted in evidence that it was far more challenging to assess an individual’s mental health via telephone than face to face. During the conversation the practitioner did not identify their role or their qualifications to Mr Swindells. 7. The documentation of the practitioner was poor and did not reflect 2 the content of the conversation which had been recorded and was available to the inquest. 8. Practitioners such as the one who saw Mr Swindells are not part of a professional /supervisory body. 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 12th December 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 17/10/2024 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.
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 13 January 2025 Thank you for the Regulation 28 report of 17th October sent to the Department of Health and Social Care about the death of Mr Leslie Andrew Swindells. 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 Swindells’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. Upon review, many concerns fall within the remit of the provider and their responsibility as an employer to meet the fundamental standards set out in Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. As the report raises several concerns regarding the care of those with suicidal ideation and complex mental health, Departmental officials have made enquiries with NHS England and the Care Quality Commission (CQC) to ensure we adequately address your concerns. NHS England has reviewed each of the concerns and provided relevant information / context to inform DHSC’s response. This is based on the information available. Without further information from the provider specifying the role function and the employment arrangements of the practitioner who saw Mr Swindells, we are unable to comment further on their training or any minimum role requirements. Mr Swindells was a patient at Hattersley Group Practice, in Cheshire, which partnered with GTD Healthcare in April 2016. Hattersley Group Practice was last inspected in March 2019, and received a rating of Good. In June 2024, the CQC were contacted by a whistleblower, raising concerns about the management of Hattersley Group Practice, by GTD Healthcare. Other concerns included outstanding workflow and a backlog of tasks not being managed safely. Operations colleagues contacted the practice to gain assurance on this matter. The practice submitted evidence of the actions they were taking to mitigate the issues. A9 In August the CQC received communication from the provider regarding Mr Swindells’s death, and they supplied additional information in September 2024 – including a timeline of events and initial action taken. In this list of actions from the provider they advised they had made changes to how they manage patients with an acute mental health problem, and they have carried out training with staff about supporting patients with suicidal tendencies. The provider contacted the CQC in October 2024 to update on the actions they proposed following Mr Swindells’s death. The CQC will continue to monitor progress on these actions. The practitioner who saw Mr Swindells had very limited training in mental health and was employed in a role described as a mental health assistant practitioner. NHS assistant practitioners are generally experienced staff who have skills and experience in a particular area of clinical practice who must always work under the direction of a registered/regulated health professional but are permitted to work alone without direct supervision. Assistant practitioners in the health and care sectors undertake higher education at academic Level 5 via an apprenticeship: Assistant practitioner (health) / Institute for Apprenticeships and Technical Education. However, there are a number of roles with similar job titles, which span nursing and the allied health professions. As the employer, GTD Healthcare would therefore need to specify the role function and university course undertaken for NHS Workforce Training and Education to provide details regarding training content. It may be helpful to note that the role of the assistant practitioner is commonly renumerated at or equivalent to NHS Agenda for Change Band 4. A lack of understanding of mental health meant that the practitioner did not recognise the level of risk Mr Swindells posed. The Institute for Apprenticeships and Technical Education states "The broad purpose of the occupation is to work alongside registered healthcare professionals in providing high quality and person-centred compassionate healthcare and support to individuals. On a daily basis, Assistant Practitioners will assist registered healthcare professionals in total patient assessment, and in the coordination of care (including referrals to other practitioners) as well as [within the limits of their competence] undertaking clinical, diagnostic and therapeutic activities according to local population and service needs”. While in this case, the practitioner is described as a ‘mental health assistant practitioner’, it is difficult to identify the level of skills and knowledge required to enable their competence, until the role function has been identified by employer. The appointment had been booked via the reception team with no triage by a doctor following a telephone call to the practice. The evidence was that a shortage of trained reception/admin staff meant that an agency worker was screening calls that day and had a limited understanding of how patients needed to be allocated. Without further information from the provider, it is not known whether the practitioner was employed directly by the GP practice or by the local primary care network (PCN) under the Additional Roles Reimbursement Scheme (ARRS). The Network Contract DES requires that A10 Additional Roles must have access to appropriate clinical supervision and administrative support. NHS England has published Supervision Guidance for PCNs and practices. The purpose of the guidance is to support PCNs and GP practices to provide effective supervision for their growing multidisciplinary teams (MDTs). While the focus of the guidance is for staff hired by PCNs via ARRS, the principles outlined could be applicable to other members of general practice teams. As guidance, it does not set out any contractual requirements of employers. PCNs and GP practices are encouraged to read the guidance in conjunction with other relevant guidance from NHS England, regulatory bodies, royal colleges and professional bodies, as it does not seek to duplicate or supersede the existing guidance / requirements. The documentation of the practitioner was poor. These concerns should be addressed by the provider and neither NHS England nor the CQC were able to respond. Practitioners such as the one who saw Mr Swindell’s are not part of a professional /supervisory body. The mental health assistant practitioner role is not currently regulated by either the Health & Care Professions Council (Allied Health Professions) or the Nursing & Midwifery Council, and there are no known plans to bring the role into regulation. Clinical responsibility and liability, therefore, for actions taken by the practitioner sits with the supervising GP, who is part of a professional and supervisory body. A link to the guidance follows: https://www.england.nhs.uk/long-read/supervision-guidance- for-primary-care-network-multidisciplinary-teams/. I hope this response is helpful. Thank you for bringing these concerns to my attention. Yours sincerely, A11
WEB
gtdhealthcare.co.uk
PHONE
E-MAIL
Date
12 December 2024
Ms Alison Much
Senior Coroner for Greater Manchester South
Manchester South Coroner's Court
1 Mount Tabor Street
Stockport
SK1 3AG
By email only:
Dear Ms Mutch
Re: Regulation 28: Report to Prevent Future Deaths
Inquest into the death of Leslie Andrew Swindells
I am writing in response to the Regulation 28 (Coroners and Justice Act 2009) Report to
Prevent Future Deaths, issued on 17 October 2024, following the inquest into the death of
Leslie Andrew Swindells. In advance of responding to the specific concerns raised in the
Report, on behalf of everyone at gtd Healthcare, I would like to extend my sincere
condolences to Mr Swindells' family and loved ones. We were all deeply saddened by his
tragic death.
I take the matters of concern identified in Section Five of your Report in turn and respond to
these as follows:
1. The Inquest heard evidence that the practitioner who saw Mr Swindells had very
limited training in mental health and was employed in a role described as a mental
health assistant practitioner. The evidence was that there was
limited
understanding of the scope of their role by GPs and what was covered by the term
routine mental health appointments.
The Practitioner who carried out Mr Swindells' telephone consultation on 23 May 2024 was
an Assistant Practitioner in Mental Health, who had been employed by gtd Healthcare ("gtd")
in this role at Hattersley Group Practice for two years.
In 2020, as part of the NHS Five Year Forward View for Mental Health, Health Education
England (now known as NHS England) developed a two-year higher apprenticeship
programme for Assistant Practitioners in Mental Health, with specialist and core modules
tailored to mental health training. The Practitioner who carried out Mr Swindells' consultation
participated in this apprenticeship programme and graduated from the University of Bolton
in 2022, with a distinction in his Foundation Degree in Health and Social Care.
New Century House, Progress Way,Off Windmill Lane, Denton, Manchester M34 2GP The Royal College of Nursing indicates that Assistant Practitioners should work as part of
the wider health and social care team, having direct contact with patients, service users and
clients. It is expected that they will operate at a level above that of Health Care Support
Workers and have a more in-depth understanding of the factors that influence a patient's
health. Following completion of the foundation degree, Assistant Practitioners are able to
work as Band 4 non-registered healthcare staff, working within a locally and defined
protocols, and escalating to senior clinicians for guidance where necessary.
In accordance with their job description, the roles and responsibilities of Assistant
Practitioners in Mental Health include: completion of annual severe mental illness ("SMI")
physical health checks, the regular depression reviews arranged following an initial mental
health consultation with a registered practitioner and also providing support for completion
of ADHD and Autism assessments. When conducting the SMI health checks and depression
reviews, Assistant Practitioners are required to complete a gtd template, and escalate any
patients who are identified as vulnerable and at high-risk of self-harm or harm to others, to
a registered practitioner for further assessment. The scope of the Assistant Practitioner in
Mental Health role is limited to non-urgent, low-level mental health reviews. They would not
be expected to be responsible for completing assessments for patients presenting with new
or deteriorating mental health concerns or symptoms.
We understand the concerns that you have raised about the level of training of gtd's
Assistant Practitioners in Mental Health and the understanding of their role within the wider
GP practice. In response to your concerns, as an organisation gtd has taken the following
steps:
•
Following consultation, on 6th November 2024 the Director of Nursing and Allied Health
Professionals made the decision that going forward, Assistant Practitioners in Mental
Health would not be employed within gtd. At present, there are no Assistant
Practitioners in Mental Health employed by gtd.
• As gtd has other Assistant Practitioner roles, we commissioned a review of all non-
registered practitioner roles, including their remit and responsibilities, to ensure that that
all roles have the required competency and management systems in place for safe
practice. This review was completed on the 27 November 2024. The policy and
subsequent recommendations will be ratified at the Clinical Quality Improvement Group
scheduled for 8th January 2025. The outcome and recommendations from the review
will be launched on the week commencing the 12th January 2025.
• As part of the launch of the review and its outcomes, details on the scope and
responsibilities of all roles will be shared with all relevant clinical and non-clinical staff
(including GPs).
•
2.
gtd's mental health lead plans to conduct a wholescale review into the organisation's
mental health processes and practices. This review will then inform the development of
the organisation's mental health processes moving forwards.
In Mr Swindells case the evidence was that he should never have had a review
undertaken by someone with such a limited understanding of mental health and
that lack of understanding of mental health meant that the practitioner did not
recognise the level of risk Mr Swindells posed.
Please see our response concerning the Assistant Practitioner's level of training and
understanding of mental health above. It is agreed that Mr Swindells should not have had
an appointment with an Assistant Practitioner in Mental Health after presenting with new
symptoms of paranoia, and that unfortunately the level of risk of self-harm posed by Mr
Swindells was not identified by the Assistant Practitioner.
At the time of Mr Swindells' death, Assistant Practitioners in Mental Health completed their
reviews on electronic templates developed by gtd staff. In this instance, the Assistant
Practitioner completed the review on the depression review template, which was designed
to be used for depression reviews only, and therefore did not include any prompts for the
user to check whether the patient was suitable to proceed with a consultation with an
Assistant Practitioner, based on their presenting complaint. Unfortunately, the Assistant
Practitioner's level of training hindered him from understanding the complexity of Mr
Swindells' presenting complaint, and therefore the need to escalate to a more senior clinician
or make an urgent referral to mental health services was not recognised. He instead agreed
a plan with Mr Swindells to refer him back to mental health services on a non-urgent basis.
Following Mr Swindells' death, gtd added an additional question to the Assistant
Practitioner's mental health template to ask whether the patient is presenting with any new
or acute symptoms. If the answer is "yes", the Assistant Practitioner was then prompted to
escalate the patient to a senior clinician. This escalation was mandatory. The change to the
template was successfully implemented on 26th September 2024 and was utilised in SMI
health checks and depression reviews until 3rd November 2024, when the role of Assistant
Practitioner in Mental Health ceased to exist in gtd.
In addition to this, we have emphasised via education sessions and our Clinical hot topics
bulletin the need for the question, 'Do you feel like harming yourself or others?' to become
a routine question to be asked in all mental health consultations. This will ensure that all our
clinicians directly consider the patient's risk of self-harm and/or suicide in each and every
appointment, and then escalate to senior clinicians or mental health services, as necessary.
3. The appointment had been booked via the reception team with no triage by a
doctor following a telephone call to the practice. The evidence was that a shortage
of trained reception/admin staff meant that an agency worker was screening calls
that day and had a limited understanding of how patients need to be allocated.
Mr Swindells' daughter first contacted Hattersley GP Practice on Tuesday 21 May 2024 and
spoke to an agency receptionist about her concerns regarding her father's mental health, in
particular his increasing paranoia and concerns about his current medication. The
receptionist confirmed their understanding that the requested appointment concerned Mr
Swindells' mental health and booked a telephone appointment with the Assistant Practitioner
in Mental Health for Thursday 23 May 2024. During this call, appropriate safety netting
advice was provided and the receptionist sign-posted Mr Swindells' daughter to Accident
and Emergency if his mental health deteriorated further prior to the planned appointment.
It is not unusual for a GP Practice to experience staffing shortages and unfortunately, whilst
the regular reception staff are aware of the need to escalate any urgent mental health
concerns to the on-call GP, the agency receptionist was not aware of this process. It is
accepted that at the time of this incident, the induction process for agency staff did not
provide sufficient guidance to ensure that they understood the correct triage and booking in
process for patients with acute mental health conditions.
We recognise the importance of the concerns which you have raised regarding the reception
triage system and in response to this we have taken the following actions:
• We have reviewed the induction process for agency staff to ensure that they are aware
of all key processes within the practice for directing patients to the appropriate clinicians.
• We introduced an interim reception triage template to assist reception staff with their
initial data gathering and to ensure that the right type of appointment was booked with
an appropriate clinician. This template prompts the receptionist to ask key questions
and then guides them to an appropriate outcome, for example, urgent same-day
appointments with a registered clinician are recommended in cases where the patient
is demonstrating severe mental health problems (including suicidal ideation, new
hallucinations, delusions or paranoia). In any cases where they are uncertain about the
appropriate outcome or concerned about the patient's symptoms, receptionists are
required to discuss the patient with the on-call GP.
•
To further ensure that all patients were seen by an appropriate clinician, access was
restricted to Assistant Practitioners' appointment books, so that only patients who have
been triaged by a registered clinician could be added. As the Assistant Practitioner in
Mental Health Role has been dissolved, this action is no longer required.
• We introduced a 'digital front door' at Hattersley Group Practice on the 18th November
2024. This online tool, which has already been successfully launched in other gtd
practices, requires the patient or a family member to complete an online triage form.
This is then reviewed by a doctor or an advanced clinical practitioner to determine the
appropriate pathway for the patient to manage their request. Where a patient is unable
to access the online forms, they can contact the practice directly and the staff will go
through the questions and complete the form on their behalf so that the form can then
be processed in the same way as had the patient completed it themselves. Forms are
reviewed daily and the system is integrated with the Electronic Patient Record, EMIS,
so that requests are saved directly to the patient's record with one click. The reviewing
clinician triages patients following the Primary Care Streaming Protocol and the patient
will then be booked for an appointment with an appropriate clinician, within the required
timeframe.
Standard Operative Procedures are in place for the management of the digital front door
and all requests are reviewed by a clinician prior to any further action such as booking
an appointment is taken. In practice, this means that receptionists will not be involved in
the process for allocating appointments, thus removing the need for training of locum
receptionists to identify the correct pathway for patients. By implementing this tool, gtd
will ensure that the patient is seen by the right person, at the right time, in the right place.
4. The evidence was that where GP practices chose to deploy staff with such limited
qualifications to see those who needed treatment for their mental health it was
essential that all those in the practice understood the limitations of the role and
that there was close supervision of the practitioner.
As discussed above in our response to Section One, the Assistant Practitioners in Mental
Health operating with gtd, who worked as Band D (Band 4 equivalent) practitioners are no
longer employed in the organisation.
These Assistant Practitioners were able to work independently of direct supervision for
routine mental health reviews, however they were unable to see any new presentations or
make any clinical decisions or plans without the agreement of a senior clinician. Therefore,
a supervisor had to be readily available and within close proximity to the Assistant
Practitioner to provide support. In each practice, gtd ensures that there is always access to
a GP or Advanced Clinical Practitioner, should an Assistant Practitioner need to escalate
any concerns about a patient.
The regular salaried GP, who worked on the same day as the Assistant Practitioner, spoke
with him at the end of his clinics to ensure that he had no issues or concerns with regards
to the patients he had reviewed. Whilst the Assistant Practitioner in Mental Health felt that
he was able to escalate concerns to the GP, in this instance his limited knowledge of the
management of paranoia meant he did not appreciate that this consultation should have
been discussed with the GP.
5. Further information is needed about how the supervision worked at the time of the
incident/how it works now.
To support staff with limited qualifications, as well as GPs and Advanced Clinical
Practitioners who supervise the Assistant Practitioners, gtd is strengthening its programme
of clinical audits. We are currently in the process of developing a web-based audit tool
("Clinical Guardian") currently used in our urgent care services to be used in primary care
and will support with the audit of clinical and non-clinical staff. The contract has been signed
with the audit software supplier, and training will take place during December, with the
intention of starting a 3-month pilot of the new process from the 2nd January 2025.
4. The Inquest heard that it was envisaged by the practice that the GP on duty would
have a supervisory role. However, it was unclear how this operated other than by
the mental health assistant escalating a concern to the duty GP.
Please see our response concerning GP supervision of the Assistant Practitioners at Section
Four above.
5. The assessment was carried out by telephone. The inquest was told that
approximately 80% of the practitioner's mental health reviews took place in this
way although it was accepted in evidence that it was far more challenging to
assess an individual's mental health via telephone than face to face. During the
conversation the practitioner did not identify their role or their qualifications to Mr
Swindells.
In agreement with Mr Swindells' daughter, a telephone appointment was booked for him to
discuss his mental health on 23 May 2024. You heard in evidence at the Inquest from a GP
at Hattersley Practice, who was well known to Mr Swindells, that he was not keen on
attending mental health appointments and tended to miss these pre-booked appointments.
It is acknowledged that it can be more challenging to assess an individual's mental health
via telephone rather than face-to-face. In circumstances such as Mr Swindells' however,
where the patient has been reluctant to attend appointments in person, and has a history of
missing appointments, a telephone consultation enables clinicians to ensure that they are
at least able to speak to the patient. Unfortunately, on this occasion, it appears that although
the type of appointment was suitable given Mr Swindells' history of non-attendance, the level
of clinician was inappropriate, and therefore the telephone consultation was not as effective
as it would have been with a more senior clinician.
Telephone reviews are an accepted practice for routine two-week mental health reviews as
the purpose is to ensure that the patient has collected, is compliant with taking their
medication, and that there are no side effects. A face-to-face consultation is not deemed
necessary for this type of review, but a referral to GP/ACP would be initiated if any concerns
were identified and face to face appointment booked in.
As part of the learning to be shared following this case, we will emphasise the need for
clinical staff to ensure they have explored all opportunities to see new presentations of
mental health conditions as a face-to-face consultation rather than via telephone.
During the appointment, the Assistant Practitioner introduced himself by name, however it
is accepted that he did not identify his specific role, qualifications or clarify that he was not
a GP. Following this incident, we have produced guidance for staff on gtd's expectations of
how they introduce themselves to patients to ensure that patients understand who is
providing their care. We have also developed posters to put up in our practices that will also
be available on the practices' web pages to ensure that patients are able to recognise the
different clinicians involved in their care.
6. The documentation of the practitioner was poor and did not reflect the content of
the conversation which had been recorded and was available to the inquest.
It is accepted that there were shortcomings in the documentation completed by the Assistant
Practitioner in Mental Health and that the documentation was not reflective of the
conversation between him and Mr Swindells.
You heard in evidence from the Assistant Practitioner that at the time of Mr Swindells'
appointment, the usual template utilised by Assistant Practitioners in Mental Health to record
their appointments and referrals, was experiencing technical issues. The Assistant
Practitioner then attempted to use a different template; however, this was impacted by the
same technical problems. To test the template before further inputting details about Mr
Swindells' appointment, the Assistant Practitioner selected random boxes and this
information then saved. Unfortunately, once he was able to complete the template, the
Assistant Practitioner did not remember to remove the inaccurate information and
proceeded to enter the appointment details. It was the Assistant Practitioner's evidence that
although inaccurate information remained on the template, the critical information reflecting
Mr Swindells' perceived condition at the time of the appointment was all accurately recorded
on this document. On the evening of 23 May 2024, the Assistant Practitioner realised his
error and remembered that the inaccuracies remained on the template and attempted to log
into the patient's record from home to rectify the records. Two attempts were made to log
into the record; however, the Assistant Practitioner was unable to amend the records.
We recognise the concerns that you have raised into the documentation concerning Mr
Swindells' appointment with the Assistant Practitioner. We have outlined at Section Two
above the changes which were introduced to the standard templates utilised by Assistant
Practitioners in their mental health and depression reviews. In addition to this, to ensure that
accurate contemporaneous records are kept of all appointments with patients, clinicians
have also been provided with hard copies of the templates to be used if they are unable to
access the clinical system templates due to IT issues.
7. Practitioners such as the one who saw Mr Swindells are not part of a
professional/supervisory body.
We agree that Assistant Practitioners are not regulated by any professional or supervisory
body. As discussed above, given that Assistant Practitioners are not accountable to any
regulatory body, they are unable to see any new presentations or make any clinical
decisions or plans without the agreement of a registered clinician. All patients who attend
appointments with Assistant Practitioners must first have been seen or triaged by a
regulated clinician, such as a GP or an Advanced Clinical Practitioner. We have outlined at
Section Three above the safeguards which we have implemented to ensure that
appointments can no longer be booked without the patient first being triaged by a registered
clinician.
Finally, I would like to take the opportunity to assure you that gtd seeks to learn from all
untoward incidents and absolutely recognises that Mr Swindells' death was the most serious
type of such incidents. As outlined above and in the evidence of the Head of Nursing and
Allied Health Professionals during the inquest, gtd has already taken learning from Mr
Swindells' sad death and will continue to do so. We are committed to sharing our learning
from this case through our training academy and with our staff to prevent any potential
reoccurrence of the tragic circumstances in which Mr Swindells died.
Yours sincerely
Director of Governance
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