Source · Prevention of Future Deaths

Suzanne Eccles

Ref: 2024-0502 Date: 19 Sep 2024 Coroner: Chris Morris Area: Greater Manchester South Responses identified: 1 / 1 View PDF

Emergency Department clinicians lack easy access to patient records from the Virtual Ward, posing a concern despite post-incident investigations and work undertaken by the Trust.

Date 19 Sep 2024
56-day deadline 14 Nov 2024
Responses identified 1 of 1
Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary
Emergency Department clinicians lack easy access to patient records from the Virtual Ward, posing a concern despite post-incident investigations and work undertaken by the Trust.
View full coroner's concerns
Whilst the court heard evidence as to significant work which has been undertaken following the Trust’s detailed investigation into the circumstances leading to Mrs Eccles’s death, it is a matter of concern that no system currently operates whereby clinicians working in the Emergency Department can easily access records made by colleagues working on the Virtual Ward.

Responses

1 respondent
Tameside and Glossop Integrated Care NHS Foundation Trust NHS / Health Body
4 Apr 2025 PDF
Action Taken

The Trust has implemented an alert process on Lorenzo to prompt staff to review the virtual ward position (in place since September 2024), prints off a hard copy of the virtual ward daily for the ED reception team, and created an electronic Virtual Ward Patient Management Board available across the acute organisation. It is working towards implementing GMCR for real-time access to shared care records, and once operational, the Lorenzo alert will be changed to prompt clinicians to review the GMCR record. (AI summary)

View full response
Chief Executive Officer Tameside and Glossop Integrated Care NHS Foundation Trust Silver Springs Fountain Street Ashton under Lyne Lancashire OL6 9RW 4th April 2025

FAO Mr Morris HM Coroner Coroner’s Court 1 Mount Tabor Street Stockport Cheshire SK1 3AG

FURTHER INFORMATION, FOLLOWING THE INQUEST TOUCHING ON THE DEATH OF MRS SUZANNE ECCLES

Reference: 35766784

I am writing to you following the inquest touching on the death of Mrs Suzanne Eccles, which concluded on 13th September 2024.

Firstly, please accept my apologies for the delay in providing this response. The letter will explain the Trusts’ immediate work undertaken following the inquest, however, the wider work has taken longer than originally anticipated to review, approve and implement.

Following the inquest, you raised some concerns that no system currently operates whereby clinicians working in the Emergency Department can easily access records made by colleagues working on the virtual ward. The Trust have reviewed this process, what is currently in place and what we plan to do to enable records to be shared.

Health and social care organisations in Greater Manchester have established the GM Care Record (GMCR) and is operated by Graphnet. It is an evolution of locality-based care records already live in Greater Manchester (e.g. Manchester Care Record, Bolton Care Record etc). However, it collates patient information from across Greater Manchester into one place, making it easily accessible for health and care professionals to inform direct care from across geographies and organisations.

The record brings together data from:
• Primary/Secondary Care (GPs/Hospitals)
• Mental Health
• Community
• Specialist Trusts (including the Christie)
• Social Care

GMCR provides real-time access to a single, secure shared care record, and allows care professionals to communicate and collaborate safely and effectively across disciplines and organisations. Professionals working in hospital, community, primary care and social care services have immediate access to the same up-to-date patient information. The user should then click through to access more detailed information for that patient from that organisation. It will not replace the Trusts’ existing care records system, but it will connect it to the GMCR.

Whilst Tameside and Glossop Integrated Care NHS Foundation Trust have access to this care record over the last few years, as a Trust we have reviewed this and consider we can, and will, utilise this more.

The Trusts’ Neighbourhood Clinical Lead has engaged in multiple discussions with the GMCR Team and the Chief Digital Office for Greater Manchester Integrated Care Partnerships (GMICB) who have confirmed that the Trust can have access to the system. The Change Control Notice (CCN) was sent to be switched on circa 16th October 2024 and we were informed it would take 3-4 weeks but this was subject to delay from the provider. It was hoped that this would have been completed sooner but was subsequently delayed due to a financial barrier. This has now been resolved.

There is now a draft contract in place with Docobo which we anticipate will be sign off by 7th April 2025 meaning the CNN can then be enacted. We have also had to collaborate with the Information Governance Lead at the ICB in relation to matters concerning GDPR so that we can ensure there will be no issues with this moving forward.

Subject to the above all being signed off, the Docobo icon on the GMCR is intended to go live on 16th April 2025. Clinical safety has been carried out by the Trusts’ Chief Clinical Information Officer so that all ED staff can see the virtual ward patient observation, then the Trust will commence the training of all ED and Digital Health staff on the GMCR which we anticipate will take 3-6 weeks to implement, from 16th April 2025.

Until the GMCR goes live, all patients admitted to the virtual ward have an alert added to community EMIS informing that the patient is on the virtual ward. EMIS is a clinical software system used in primary care, acute care and community pharmacy. Following the period of care, this alert is removed. Once the GMCR is operational, the alert process will remain on EMIS but will be changed to prompt clinicians to review the GMCR record/care plans. This will be led by Digital Health.

A hard copy of the virtual ward is being printed off daily by Digital Health and a copy is provided to the reception team in the Emergency Department (ED), so that out of hours and ED are aware of who is being monitored.

In addition to the above, an electronic Virtual Ward Patient Management Board has been created and is available across the acute organisation, with live and current patient updates across all departments. Bed managers are able to see and access this Ward Board. It is just out of development and is being moved to the Emergency Departments Clinical Portal System, so that it will make it easier to see the list of patients currently under the care of the Virtual Ward. The board provides information about the level of risk that a patient is at whilst on Virtual Ward and the number of contacts that they have had each day and what condition they are being monitored/supported at home for. This board enables ED Teams to have full access to patients twenty-four hours each day, seven days a week.

Once the GMCR record is operational, ED will have their own direct access to the GMCR through the icon. Until this is launched on 16th April 2025, there is an alert process on Lorenzo that will prompt staff to review the position on Virtual Ward which has been in place since the inquest in September 2024.

I do hope that this letter provides you with further reassurance following the inquest, however, should you have any queries arising from the content of this letter or require further information or clarification, please do not hesitate to contact Legal Services on or

Report sections

Investigation and inquest
On 10th April 2024, Alison Mutch, Senior Coroner for Greater Manchester (South), opened an inquest into the death of Suzanne Rose Eccles who died on 3rd March 2024 at Tameside General Hospital, Ashton-under-Lyne, aged 72 years. The investigation concluded with an inquest which I heard on 13th September 2024. The inquest determined that Mrs Eccles died as a consequence of:-
1) a) Pneumonia and Empyema; b) Lung Cancer (operated 16th February 2024) II Ischaemic Heart Disease The conclusion of the inquest was a Narrative Conclusion, to the effect that Mrs Eccles died as a consequence of complications arising from necessary surgery which had not been identified in the course of previous hospital attendances.
Circumstances of the death
Mrs Eccles died on 3rd March 2024 at Tameside General Hospital having developed Pneumonia and Empyema against a background of recent surgery for lung cancer. Her death was contributed to by Ischaemic Heart Disease. In the days leading up to her death, Mrs Eccles had been seen in the Same Day Emergency Care Unit and Emergency Department, and also been a patient on the Virtual Ward.
Copies sent to
law, and the Trust’s legal team. the Care Quality Commission and NHS Greater Manchester Integrated Care

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Report details

Reference
2024-0502
Date of report
19 September 2024
Coroner
Chris Morris
Coroner area
Greater Manchester South

Responses identified

Responses identified 1 of 1
All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 14 Nov 2024.

Sent to

Tameside and Glossop Integrated Care NHS Foundation Trust

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