Tafford Clinical Commissioning Group
NHS / Health Body
Action Planned
Trafford CCG will share the PFD report and responses with all GP practices via their 'Practice Briefing' to disseminate learning regarding prescribing appropriate medication for vulnerable patients, 'ASK MY GP' system challenges, and home visits. They also plan to signpost practices to digital support and review implementation issues. (AI summary)
View full response
Dear Ms Mutch,
Re: Mr Alphonso Alexander Shearer
I write in response to the Prevention of Future Death (PFD) notice dated 28th April 2022 and respond accordingly to the matters raised in relation to the death of the late Mr Shearer. Firstly, on behalf of Trafford Clinical Commissioning Group (CCG), I would like to offer Mr Shearer’s family our sincerest condolences and we hope this response helps to answer any questions that remain outstanding for them.
You specifically asked us as a CCG to respond to section 5: Coroner’s Concerns, and we have been working with the GP’s and staff at North Trafford Group Practice (Mr Shearer’s GP practice) to investigate those concerns and gain an understanding of the learning so that we can share this with all our practices across Trafford.
The practice has provided a full and thorough response (attached to this response) to each of the points raised which include the practice level learning. Our response aims to enhance this further to offer assurance to you and Mr Shearer’s family that we have considered the action taken by the individual practice and we have shared this with all our practices in Trafford and encouraged them to implement the same systems to maximise the learning and in turn, help prevent any similar experiences for our patients and their families.
The CCG response to each of the concerns are provided below;
1. The inquest heard that Mr Shearer was frail and vulnerable with very poor swallow. When prescribing the clinicians did not recognise or have a system to flag up the need for liquid antibiotics rather than tablet antibiotics. This led to him not being able to commence antibiotics on the day he was identified as needing them. The inquest heard that it is important that in the community particularly for the vulnerable there is a system for recognising what form of antibiotics are most appropriate to prescribe to avoid delay.
Private & Confidential
F.A.O: Alison Mutch HM Senior Coroner
HM Coroner’s Court 1 Mount Tabor Street Stockport SK1 3AG
1st Floor Trafford Town Hall Talbot Road Stretford Manchester M32 0TH
Tel:
E-mail:
23rd June 2022
2
The practice has undertaken a review of the EMISWeb system which is used by all practices in Trafford, this is where all patient appointments and consultations are recorded. The system does allow for system warning alerts (often referred to by practice staff as “pop-ups”) when accessing a patient record to identify those who may need specific types of medication based around their personal needs, including swallowing difficulties. The practice is now in the process of identifying those patients who are coded with swallowing difficulties as well as those who are already receiving liquid medication, nutritional supplements or feeds. This will be carried out over the next 4 weeks and for each of those patients a “pop-up” up will be added to alert clinicians of the patient’s specific requirements. The practice Medicines Management Team are also supporting this work to help avoid any unnecessary delays in a patient’s medication. As a CCG we offer support with EMISWeb system to develop system alerts as well as other system capabilities and all our practices have had the training to be able to manage this system on a day to day basis. Whilst we are not responsible for the monitoring of the operational systems of our practices, we use our quarterly educational events which practice staff attend to share any changes to the system and share learning from events such as this. We are really pleased that the practice is undertaking this exercise to ensure patients with specific needs are managed appropriately.
2. The inquest heard that the AskmyGP system had been challenging for those involved with Mr Shearer and had made communication harder. The evidence identified that this was a particular issue for more vulnerable patients and their families
3. The inquest heard that he had not been seen face to face by a GP and that is meant that full extent of his deterioration was not recognised until he was seen by a paramedic from the practice who called an ambulance.
The adoption of AskmyGP during 2020 was planned as part of the NHS Long Term Plan to improve digital access for patients. This was expedited during the COVID-19 pandemic due to the advantages it offered in remote working. 70% of our practices in Trafford use this system which has enabled patients to access their practice without the need to physically attend on site which was encouraged during the pandemic where possible. The remaining 30% of our practices use similar digital systems with the same capabilities. These digital systems do not mean that that face to face appointments are not available. Each request on these systems are reviewed by a clinician and a decision is made on the method of consultation, which could be by telephone, email, video consultation, face to face or a home visit. Since the start of the pandemic all practices have been working in a challenging environment and had only seeing patients face to face where necessary, the digital system capabilities have helped to facilitate this and continues to be an effective way of managing patient
3
requests for treatment. Where patients are unable to access digital systems, practices should offer equitable alternative access to those patients such as phone calls in the case of Mr Shearer and those phone calls should be addressed effectively. As part of their review of the alert system on EMISWeb, North Trafford Group Practice are also placing alerts on the records of those patients who may struggle with digital access, this will include specific requirements such as the need for an interpreter, or additional support to undertake a consultation. We are pleased that the practice is monitoring the effectiveness of this system by discussing the learning from this event at their next Patient Participation Group, this group includes members from our local Healthwatch who act as advocates for our patient’s in Trafford. During May 2021 the CCG also undertook a review of the patient experience of AskmyGP and 90% of the patients who had used the system were highly satisfied with it. With this said we are also currently undertaking a piece of work to establish who is using the digital systems, and more importantly who isn’t? This will enable us to reduce the inequalities in digital access across the borough. We will ensure that any learning is shared with our practices as part of this work.
The AskmyGp system does allow for a request for a home visit and these are assessed by clinicians to determine the urgency. The clinician would usually make the initial contact by telephone to determine the history of the presenting condition and determine how best to arrange an assessment. In Mr Shearer’s case, I understand the family had difficulty arranging a home visit and the practice state that this was due to their request not being logged on the system on 17th August 2021 which was an error. They have reminded all reception staff of the importance of accurately recording all requests for home visits in the clinical system so that they are referred to clinicians for an assessment. This will be reinforced further during training sessions for reception staff. As I mentioned earlier the CCG is not responsible for the monitoring of how our practices operate their systems, however we are responsible for ensuring our GP practices are offering high quality care including equal access across the borough and support for those without digital access. This is something we will continue to monitor via our current Primary Care Health Inequalities Quality Aims plan. This plan has been in place since November 2020 and improving access to our GP practices is an ongoing theme within this.
This extremely sad case has highlighted a number of issues that can occur in healthcare systems and processes where a vulnerable patient may be at risk of a delay in treatment. This report gives us a real example to use in reminding all GPs in Trafford about those risks, what clinicians should be considering in terms of their own practice systems and the resources available to support clinicians in the management of vulnerable patients with complex needs. Over the next week, we will be sharing a copy of the Regulation 28 along with the responses to this in our “Practice Briefing”, an email update which is sent out to over 400 Primary Care staff in Trafford twice a week.
4
By way of further assurance, I am pleased to say that we currently have 27 practices in Trafford, 25 of those are rated as “Good” with the Care Quality Commission (CQC) and 2 are rated as “Outstanding”. The CQC process of monitoring and inspecting GP practices covers areas of person-centered care which takes into account the needs of different people and timely access to care and treatment. We don’t have any practices with any outstanding action plans or regulatory notices with CQC at this time, and all of our practices are subject to the current routine CQC monitoring process in place.
Our Quality Team meet regularly with our local CQC Inspector to discuss any areas of concern and where we can support our practices maintain high quality services. We also have an internal Quality Assurance Framework where we use data and soft intelligence to enable us to monitor elements of quality with our practices on a regular basis.
We hope our response is satisfactory for the issues raised, please do not hesitate to contact us should you require further clarification
Dr
Medical Director
Re: Mr Alphonso Alexander Shearer
I write in response to the Prevention of Future Death (PFD) notice dated 28th April 2022 and respond accordingly to the matters raised in relation to the death of the late Mr Shearer. Firstly, on behalf of Trafford Clinical Commissioning Group (CCG), I would like to offer Mr Shearer’s family our sincerest condolences and we hope this response helps to answer any questions that remain outstanding for them.
You specifically asked us as a CCG to respond to section 5: Coroner’s Concerns, and we have been working with the GP’s and staff at North Trafford Group Practice (Mr Shearer’s GP practice) to investigate those concerns and gain an understanding of the learning so that we can share this with all our practices across Trafford.
The practice has provided a full and thorough response (attached to this response) to each of the points raised which include the practice level learning. Our response aims to enhance this further to offer assurance to you and Mr Shearer’s family that we have considered the action taken by the individual practice and we have shared this with all our practices in Trafford and encouraged them to implement the same systems to maximise the learning and in turn, help prevent any similar experiences for our patients and their families.
The CCG response to each of the concerns are provided below;
1. The inquest heard that Mr Shearer was frail and vulnerable with very poor swallow. When prescribing the clinicians did not recognise or have a system to flag up the need for liquid antibiotics rather than tablet antibiotics. This led to him not being able to commence antibiotics on the day he was identified as needing them. The inquest heard that it is important that in the community particularly for the vulnerable there is a system for recognising what form of antibiotics are most appropriate to prescribe to avoid delay.
Private & Confidential
F.A.O: Alison Mutch HM Senior Coroner
HM Coroner’s Court 1 Mount Tabor Street Stockport SK1 3AG
1st Floor Trafford Town Hall Talbot Road Stretford Manchester M32 0TH
Tel:
E-mail:
23rd June 2022
2
The practice has undertaken a review of the EMISWeb system which is used by all practices in Trafford, this is where all patient appointments and consultations are recorded. The system does allow for system warning alerts (often referred to by practice staff as “pop-ups”) when accessing a patient record to identify those who may need specific types of medication based around their personal needs, including swallowing difficulties. The practice is now in the process of identifying those patients who are coded with swallowing difficulties as well as those who are already receiving liquid medication, nutritional supplements or feeds. This will be carried out over the next 4 weeks and for each of those patients a “pop-up” up will be added to alert clinicians of the patient’s specific requirements. The practice Medicines Management Team are also supporting this work to help avoid any unnecessary delays in a patient’s medication. As a CCG we offer support with EMISWeb system to develop system alerts as well as other system capabilities and all our practices have had the training to be able to manage this system on a day to day basis. Whilst we are not responsible for the monitoring of the operational systems of our practices, we use our quarterly educational events which practice staff attend to share any changes to the system and share learning from events such as this. We are really pleased that the practice is undertaking this exercise to ensure patients with specific needs are managed appropriately.
2. The inquest heard that the AskmyGP system had been challenging for those involved with Mr Shearer and had made communication harder. The evidence identified that this was a particular issue for more vulnerable patients and their families
3. The inquest heard that he had not been seen face to face by a GP and that is meant that full extent of his deterioration was not recognised until he was seen by a paramedic from the practice who called an ambulance.
The adoption of AskmyGP during 2020 was planned as part of the NHS Long Term Plan to improve digital access for patients. This was expedited during the COVID-19 pandemic due to the advantages it offered in remote working. 70% of our practices in Trafford use this system which has enabled patients to access their practice without the need to physically attend on site which was encouraged during the pandemic where possible. The remaining 30% of our practices use similar digital systems with the same capabilities. These digital systems do not mean that that face to face appointments are not available. Each request on these systems are reviewed by a clinician and a decision is made on the method of consultation, which could be by telephone, email, video consultation, face to face or a home visit. Since the start of the pandemic all practices have been working in a challenging environment and had only seeing patients face to face where necessary, the digital system capabilities have helped to facilitate this and continues to be an effective way of managing patient
3
requests for treatment. Where patients are unable to access digital systems, practices should offer equitable alternative access to those patients such as phone calls in the case of Mr Shearer and those phone calls should be addressed effectively. As part of their review of the alert system on EMISWeb, North Trafford Group Practice are also placing alerts on the records of those patients who may struggle with digital access, this will include specific requirements such as the need for an interpreter, or additional support to undertake a consultation. We are pleased that the practice is monitoring the effectiveness of this system by discussing the learning from this event at their next Patient Participation Group, this group includes members from our local Healthwatch who act as advocates for our patient’s in Trafford. During May 2021 the CCG also undertook a review of the patient experience of AskmyGP and 90% of the patients who had used the system were highly satisfied with it. With this said we are also currently undertaking a piece of work to establish who is using the digital systems, and more importantly who isn’t? This will enable us to reduce the inequalities in digital access across the borough. We will ensure that any learning is shared with our practices as part of this work.
The AskmyGp system does allow for a request for a home visit and these are assessed by clinicians to determine the urgency. The clinician would usually make the initial contact by telephone to determine the history of the presenting condition and determine how best to arrange an assessment. In Mr Shearer’s case, I understand the family had difficulty arranging a home visit and the practice state that this was due to their request not being logged on the system on 17th August 2021 which was an error. They have reminded all reception staff of the importance of accurately recording all requests for home visits in the clinical system so that they are referred to clinicians for an assessment. This will be reinforced further during training sessions for reception staff. As I mentioned earlier the CCG is not responsible for the monitoring of how our practices operate their systems, however we are responsible for ensuring our GP practices are offering high quality care including equal access across the borough and support for those without digital access. This is something we will continue to monitor via our current Primary Care Health Inequalities Quality Aims plan. This plan has been in place since November 2020 and improving access to our GP practices is an ongoing theme within this.
This extremely sad case has highlighted a number of issues that can occur in healthcare systems and processes where a vulnerable patient may be at risk of a delay in treatment. This report gives us a real example to use in reminding all GPs in Trafford about those risks, what clinicians should be considering in terms of their own practice systems and the resources available to support clinicians in the management of vulnerable patients with complex needs. Over the next week, we will be sharing a copy of the Regulation 28 along with the responses to this in our “Practice Briefing”, an email update which is sent out to over 400 Primary Care staff in Trafford twice a week.
4
By way of further assurance, I am pleased to say that we currently have 27 practices in Trafford, 25 of those are rated as “Good” with the Care Quality Commission (CQC) and 2 are rated as “Outstanding”. The CQC process of monitoring and inspecting GP practices covers areas of person-centered care which takes into account the needs of different people and timely access to care and treatment. We don’t have any practices with any outstanding action plans or regulatory notices with CQC at this time, and all of our practices are subject to the current routine CQC monitoring process in place.
Our Quality Team meet regularly with our local CQC Inspector to discuss any areas of concern and where we can support our practices maintain high quality services. We also have an internal Quality Assurance Framework where we use data and soft intelligence to enable us to monitor elements of quality with our practices on a regular basis.
We hope our response is satisfactory for the issues raised, please do not hesitate to contact us should you require further clarification
Dr
Medical Director