Greater Manchester Integrated Care
Integrated Care Board
Action Taken
NHS Greater Manchester Integrated Care highlights actions taken including presenting findings to learning forums, introducing electronic white boards in patient areas, completing analgesic dosing audits, distributing a Pharmacy Safe Bulletin to Multidisciplinary Teams, and sharing learning with the Greater Manchester System Quality Group. They will also cascade shared learning from this and similar cases to professionals through governance and learning forums. (AI summary)
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Dear Ms Mutch
Re: Regulation 28 Report to Prevent Future Deaths – Marjorie Walker 27/05/20
Thank you for your Regulation 28 Report dated 15/06/22 concerning the sad death of Marjorie Walker on 27/05/20. On behalf of NHS Greater Manchester Integrated Care (NHS GM), I would like to begin by offering our sincere condolences to Ms Walkers family for their loss.
Thank you for highlighting your concerns during Ms Walkers Inquest which concluded on 3 March 2022. On behalf of NHS GM, I apologise that you have had to bring these matters of concern to our attention but it is also very important to ensure we make the necessary improvements to the quality and safety of future services.
The inquest concluded that Marjorie’s death was a result of 1a) Combined effects of gabapentin, morphine, buprenorphine on a background of congestive cardiac failure, chronic renal failure, chronic obstructive pulmonary disease, bronchopneumonia, cerebrovascular disease and hyperkalaemia. Following the inquest, you raised concerns in your Regulation 28 Report to NHS GM that there is a risk future deaths will occur unless action is taken.
I hope the response below demonstrates to you and Ms Walker’s family that NHS GM has taken the concerns you have raised seriously and will learn from this as a whole system.
This letter addresses the issues that fall within the remit of NHSGM and how we can share the learning from this case.
Completion of DNACPR documentation Following the trust’s own investigation, the findings were presented to the Surgical PASQAF and Grand Round. This is a learning forum attended by all clinical staff across all divisions of the organisation. Electronic white boards have been introduced in all patient areas which assist in improving oversight of patient needs, flow and bed capacity and highlighting concerns through a control centre. Patient safety information including falls risk, nutritional needs and medical conditions can also be highlighted using the boards. DNACPR status is included within the options available for staff. Using the DNACPR feature allows clinical teams to identify where one is in place or where one may be required. This is discussed within safety huddles in each clinical area at the start of each shift. These statuses can be updated at any time supporting early identification of patients admitted who may not have had such decisions made in the community, or whose condition may have changed necessitating consideration of this.
A trust-wide DNACPR audit took place in February and March 2022 with actions identified around
4th Floor, Piccadilly Place, Manchester M1 3BN Tel: 0161 6257791 www.gmintegratedcare.org.uk DNACPR discussion and completion of appropriate documentation. The findings were presented to the Trust Deteriorating Patient Group and Mortality Steering Group. A medical lead has been appointed to support the identified actions and strengthen the overall process. This has included reviewing the e- learning modules which support DNACPR training. This training will be made available to all medical staff and the specialist palliative care nursing team.
Access to specialist pain clinics Provision of pain management services are within the standard contract. This is agreed at a national level with no specification for this area. A contracted plan is agreed at the start of each financial year to include activity for patients who require inpatient care, clinical interventions on a day case basis and specialist management and review in outpatient clinics.
Patients who have two or more long term conditions (including COPD and heart failure), are eligible for referral to the Trust Extensive Care Team. This is a specialist team for patients with long term conditions focused on living independently, managing their condition to avoid hospital admission, which may have also identified that specialist advice relating to pain management may have been beneficial.
Within Tameside there is a single commissioning function for health and social care. There are strong links between the five neighborhoods or primary care networks and the trust. The trust is currently discussing how best to share the learning from this inquest with GP partners, including facilitated discussion about best practice and available services.
Understanding of risks associated with gabapentin usage In response to the missed opportunities to appreciate the dose of morphine and gabapentin in relation to the reduced kidney function, the trust completed a baseline analgesic dosing audit in 2021. A re-audit was undertaken following the introduction of new medication charts in December 2021. The audit was reviewed by the Medicines Safety Group and Pharmacy Governance and further learning identified and actioned. A Pharmacy Safe Bulletin has been distributed to Multidisciplinary Teams. A presentation was also provided to the Trust wide Grand Round.
Actions taken or being taken to share learning across Greater Manchester.
1. Learning to be presented/shared with the Greater Manchester System Quality Group. This meeting is attended by commissioners, including commissioners of specialist services, regulators, Healthwatch and NICE.
2. Shared learning from this and similar cases at Greater Manchester and borough level will be cascaded to professionals through relevant governance and learning forums.
In conclusion, key learning points and recommendations will be monitored to ensure they are embedded within practice. NHS GM is committed to improving outcomes for the population of Greater Manchester.
I hope this response demonstrates to you and Ms Walkers’ family that NHS GM has taken the concerns you have raised seriously and is committed to work together as a system including our service users, carers and families to improve the care provided.
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.
4th Floor, Piccadilly Place, Manchester M1 3BN Tel: 0161 6257791 www.gmintegratedcare.org.uk
Re: Regulation 28 Report to Prevent Future Deaths – Marjorie Walker 27/05/20
Thank you for your Regulation 28 Report dated 15/06/22 concerning the sad death of Marjorie Walker on 27/05/20. On behalf of NHS Greater Manchester Integrated Care (NHS GM), I would like to begin by offering our sincere condolences to Ms Walkers family for their loss.
Thank you for highlighting your concerns during Ms Walkers Inquest which concluded on 3 March 2022. On behalf of NHS GM, I apologise that you have had to bring these matters of concern to our attention but it is also very important to ensure we make the necessary improvements to the quality and safety of future services.
The inquest concluded that Marjorie’s death was a result of 1a) Combined effects of gabapentin, morphine, buprenorphine on a background of congestive cardiac failure, chronic renal failure, chronic obstructive pulmonary disease, bronchopneumonia, cerebrovascular disease and hyperkalaemia. Following the inquest, you raised concerns in your Regulation 28 Report to NHS GM that there is a risk future deaths will occur unless action is taken.
I hope the response below demonstrates to you and Ms Walker’s family that NHS GM has taken the concerns you have raised seriously and will learn from this as a whole system.
This letter addresses the issues that fall within the remit of NHSGM and how we can share the learning from this case.
Completion of DNACPR documentation Following the trust’s own investigation, the findings were presented to the Surgical PASQAF and Grand Round. This is a learning forum attended by all clinical staff across all divisions of the organisation. Electronic white boards have been introduced in all patient areas which assist in improving oversight of patient needs, flow and bed capacity and highlighting concerns through a control centre. Patient safety information including falls risk, nutritional needs and medical conditions can also be highlighted using the boards. DNACPR status is included within the options available for staff. Using the DNACPR feature allows clinical teams to identify where one is in place or where one may be required. This is discussed within safety huddles in each clinical area at the start of each shift. These statuses can be updated at any time supporting early identification of patients admitted who may not have had such decisions made in the community, or whose condition may have changed necessitating consideration of this.
A trust-wide DNACPR audit took place in February and March 2022 with actions identified around
4th Floor, Piccadilly Place, Manchester M1 3BN Tel: 0161 6257791 www.gmintegratedcare.org.uk DNACPR discussion and completion of appropriate documentation. The findings were presented to the Trust Deteriorating Patient Group and Mortality Steering Group. A medical lead has been appointed to support the identified actions and strengthen the overall process. This has included reviewing the e- learning modules which support DNACPR training. This training will be made available to all medical staff and the specialist palliative care nursing team.
Access to specialist pain clinics Provision of pain management services are within the standard contract. This is agreed at a national level with no specification for this area. A contracted plan is agreed at the start of each financial year to include activity for patients who require inpatient care, clinical interventions on a day case basis and specialist management and review in outpatient clinics.
Patients who have two or more long term conditions (including COPD and heart failure), are eligible for referral to the Trust Extensive Care Team. This is a specialist team for patients with long term conditions focused on living independently, managing their condition to avoid hospital admission, which may have also identified that specialist advice relating to pain management may have been beneficial.
Within Tameside there is a single commissioning function for health and social care. There are strong links between the five neighborhoods or primary care networks and the trust. The trust is currently discussing how best to share the learning from this inquest with GP partners, including facilitated discussion about best practice and available services.
Understanding of risks associated with gabapentin usage In response to the missed opportunities to appreciate the dose of morphine and gabapentin in relation to the reduced kidney function, the trust completed a baseline analgesic dosing audit in 2021. A re-audit was undertaken following the introduction of new medication charts in December 2021. The audit was reviewed by the Medicines Safety Group and Pharmacy Governance and further learning identified and actioned. A Pharmacy Safe Bulletin has been distributed to Multidisciplinary Teams. A presentation was also provided to the Trust wide Grand Round.
Actions taken or being taken to share learning across Greater Manchester.
1. Learning to be presented/shared with the Greater Manchester System Quality Group. This meeting is attended by commissioners, including commissioners of specialist services, regulators, Healthwatch and NICE.
2. Shared learning from this and similar cases at Greater Manchester and borough level will be cascaded to professionals through relevant governance and learning forums.
In conclusion, key learning points and recommendations will be monitored to ensure they are embedded within practice. NHS GM is committed to improving outcomes for the population of Greater Manchester.
I hope this response demonstrates to you and Ms Walkers’ family that NHS GM has taken the concerns you have raised seriously and is committed to work together as a system including our service users, carers and families to improve the care provided.
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.
4th Floor, Piccadilly Place, Manchester M1 3BN Tel: 0161 6257791 www.gmintegratedcare.org.uk