Trevor Curry

Dear Miss Hamilton-Deeley Re: The late Mr Trevor John Curry Thank you for your letter of 20 March 2017, enclosing your report written under Paragraph 7, Schedule 5 of The Coroners & Justice Act 2009 and Regulations 28 and 29 of the Coroner's (Investigations) Regulations 2013, a copy of the text of the whole rule and the Record of Inquest. Firstly, may I offer my sincere condolences to Mr Curry's family on their tragic loss. This letter is intended to set out the learning and actions we have taken at Sussex Partnership NHS Foundation Trust following Mr Curry's death and I hope it provides you and Mr Curry's family with assurance that we have taken the lessons you have highlighted extremely seriously. I am sorry the information from Mr Curry's sister that Mr Curry was being seen by a cardiologist and he was suffering with palpitations was not recorded in the health records. , General Manager -Acute and Urgent Care Services for Brighton and Hove drafted a briefing for staff highlighting your concerns to ensure the lessons are widespread throughout the Trust. The briefing and ongoing team meetings and clinical supervision sessions have been used highlight the importance of good clear documentation in our new electronic health records system. This has assisted our learning and an improvement in our recording. Senior members of staff such as Ward Managers and Matrons at Mill View Hospital complete documentation audits to ensure the expected standards of documentation are met. In relation to the timely requests for primary care records and information about our patients, I am pleased to say a new system has been introduced. The new system, now in use is as follows; The Crisis Resolution and Home Treatment Team administrators request a copy of the primary care, summary care record, or encounter report, from the GP

Head office: Sussex Partnership NHS Foundation Trust, Swandean, Arundel Road, Worthing, West Sussex, BN13 3EP

A teaching trust of Brighton and Sussex Medical School

practice for all new patients admitted to Mill View hospital. This is done within 48 hours of admission and the administrators verify all new patient admissions at the daily Acute Referral Meeting (ARM) which is attended by the Bed Manager. The Crisis Resolution and Home Treatment Team administrators upload the primary care, summary care record / encounter report to the Trust's electronic health records system 'Carenotes' which all clinical staff in the Trust have access to. Laminated copies of the guidance has been circulated to the wards at Mill View Hospital and it is displayed for staff as a reminder and for easy reference. Please find enclosed our new Protocol for the Management of Primary Care Clinical Information for all Patients admitted to acute inpatient services for your information. In addition, (Chief Pharmacist) produced guidance for staff regarding the importance of obtaining the primary care, summary care record, which was distributed to Trust staff and taken to staff meetings for sharing and discussion. Clinicians in both primary and secondary care can access summary care records using an NHS Smartcard, once they are set up on the national system. Furthermore, the Trust is currently looking to establish an "opt out" system so that patients in contact with our services are informed that summary care record access will occur by default unless they specify that it may not, (unless a best interest decision needs to be made). (Chief Pharmacist) has confirmed that this guidance is now included in the induction pack for all new junior doctors joining the Trust. The learning from Mr Curry's death has been included in the Trust's quarterly quality report available to all Trust staff and our Clinical Commissioning Groups. I note your conclusion confirmed that Mr Curry's treatment and medications during the course of his admission were appropriate and made no contribution to his sudden death. Nonetheless, we take each and every death very seriously. As a result of the lessons from your inquest, and as a legacy to Mr Curry, we have learnt from this, and I hope you feel reassured that we have introduced an achievable and improved system for the acute wards to obtain such important information to assist us with the care of our patients. We are committed to continually learning, improving and strengthening relationships with our primary care colleagues for the benefit of our patients and their families and carers.