Source · Prevention of Future Deaths

Alexander Theodossiadis

Ref: 2021-0412 Coroner: Kevin McLoughlin Area: West Yorkshire (Eastern) Responses identified: 4 / 3 View PDF

Failures in patient transfer included no nurse escort or written handover. Prolonged A&E stay lacked clear treatment pathways and timely lumbar puncture. No falls risk assessment despite patient confusion contributed to a fall.

Responses identified 4 of 3

Community health care and emergency services related deaths Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary

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(1) Evidence was taken at the Inquest which indicated Mr Theodossiadis was moved from one hospital within the Trust to another, close to midnight on 25th January 2020. Despite being severely unwell with bacterial meningitis and in a confused state he was not accompanied by a nurse escort, nor was any written handover instruction or briefing note provided for the nurses receiving him, in breach of the prevailing Trust handover guidance.

(2) Mr Theodossiadis remained in A&E for some 10 hours in total, despite the nature of his condition. Concern was expressed at the Inquest in relation to firstly, the absence of clear instructions regarding the need for a lumbar puncture within four hours of admission; secondly, a clear pathway to an appropriate treatment location; thirdly, any directions specifying the timetable in which action was required in response to a life-threateninq condition.

(3) The Inquest heard evidence that practice differs nationally on the need for a lumbar puncture in cases of meningitis. The absence of clear leadership on this issue nationally does not assist clinicians who may encounter this relatively rare, but serious condition.

(4) Despite spending 1Ohours in A&E and displaying increasing signs of confusion he was seen to be trying to get off his hospital bed which created a risk of falls, no assessment of the falls risk was carried out. In consequence, the receiving ward J27 at St James's University Hospital, Leeds were not forewarned of the risk offalls. He fell from his hospital bed within approximately 10 minutes of being placed in a side room on his own.

Responses

4 respondents

Royal College of GPs Other

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Action Taken

The Royal College of General Practitioners states that since the pandemic, GP practice custom and practice has changed, now requiring detailed information from patients when requesting appointments. This new system involves clinicians as the initial point of consultation and triage, which is in line with the coroner's request for more information gathering. (AI summary)

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Dear Mr McLoughlin, Regulation 28 Report to Prevent Future Deaths - touching on the death of Alexander George Theodossiadis Thank you for your letter of 3 December 2021. am responding on behalf of the Royal College of General Practitioners 35 Honorary Secretary to Council Firstly, can convey our condolences to the family and friends of Alexander Theodossiadis. was saddened t0 read of Alexanders passing: The Royal College of General Practitioners (RCGP) is the largest membership organisation in the United Kingdom solely for GP It aims to encourage and maintain the highest standards of general medical practice and to act as the 'voice' of GPs on issues concerned with education; training; research; and clinical standards Founded in 1952,the RCGP has just over 54,000 members who are committed to improving patient care, developing their own skills and promoting general practice asa discipline: You have asked the RCGP about GP reception staff and their training for the role. In particular whether receptionists could ask more questions of patients who do not request urgent appointments The report details that the events leading to the inquest took place before the Coronavirus Pandemic The custom and practice at the time was t0 offer and book the first available appointment without questioning of the patient If the patient wanted 2 more urgent appointment they could request one Reception staff are not clinically trained although they do have come knowledge They would signpost rather than perform clinical triage. They had access to the GP and could ask for different priority if requested by the patient Royal College of General Practitioners 30 Euston Square, London,NW1 2FB Tel: 020 3188 7400 info@rcgporguk rcgporguk Patron: HRH The Duke of Edinburgh (1972-2021) Registered Charity Number 223106

At that time the service was already difficulty providing sufficient appointments_ As the system came under progressive strain urgent patients were prioritised. As a consequence; the length of time to a non-urgent appointment increased Patients could book an appointment with GP without explanation if they wished When that was a choice of urgent today or unrestricted in three or four days it was acceptable No one in the system wanted there to be a three week wait for routine appointments If the patient had asked for an urgent appointment that day; one might have been provided but the narrative suggests that the patient felt he had a viral illness at that time Since the pandemic the custom and practice has completely changed Detailed information i5 requested from patients when they request appointments The information given is reviewed and frequently a telephone call arranged with a clinician to consult with the patient There are also different options to reach the practice now Direct attendance without a booked face to face appointment is discouraged but telephone and email are more available After an initial dip in first lockdown the number of requests for consultations has increased There are figures from NHS Digital (Expermental Figures and therefore caution is advised) that showa 10% increaze in appointments between October 2019 October 2021. Patients now receive clinician an appointment a5 3 way of dealing efficiently with the increased numbers of appointment requests This has meant that the option of waiting and direct booking with a named professional including GP js no longer available When patients are first consulted by telephone those that need them are brought down for face-to-face consultations. The system has moved from requests to receptionists to clinicians a5 initial point of consultation and tnage. This is not the same as the suggested option of receptionists asking for information but should provide a higher level of clinical safety and service There is no fommal requirement for practices t0 consult in this way they could still offer open face t0 face appointments, but most do not The telephone clinician appointments are usually more rapidly available. This is in line with your request for more information to be gathered from patients when booking appointments trust that this reply is helpful and if you have any questions, please do not hesitate to contact Me.

St Jamess University Hospital NHS / Health Body

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Action Taken

St James's University Hospital has updated its transfer policy, developed a comprehensive transfer checklist, and embedded a formal sepsis pathway. They have also implemented specific pathways for suspected meningitis and various falls prevention measures including education, safety huddles, and yellow socks for at-risk patients. (AI summary)

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Dear Mr McLoughlin INQUEST TOUCHING THE DEATH OF ALEXANDER THEODOSSIADIS (Deceased) I refer to your correspondence of 3rd December 2021, regarding the inquest touching the death of Mr Alexander Theodossadis and the Regulation 28 Report to Prevent Future Deaths in respect of this case. I can confirm that the contents of your Regulation 28 Report have been shared with the relevant staff to enable us to provide you with a comprehensive response. In your report you highlight that your matters of concern were as follows: (1) Evidence was taken at the Inquest which indicated Mr Theodossiadis was moved from one hospital within the Trust to another, close to midnight on 25th January
2020. Despite being severely unwell with bacterial meningitis and a confused state he was not accompanied by a nurse escort, nor was any written handover instruction or briefing note provided for the nurses receiving him, in breach of the prevailing Trust handover guidance. (2) Mr Theodossiadis remained in A&E for some 10 hours in total, despite the nature of his condition. Concern was expressed at the Inquest in relation to first, the absence of clear instructions regarding the need for a lumbar puncture within four hours of admission; secondly, a clear pathway to an appropriate treatment location; thirdly, any directions specifying the timetable in which action was required in response to a life-threatening condition.

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(3) The inquest heard evidence that practice differs nationally on the need for a lumbar puncture in cases of meningitis. The absence of clear leadership on this issue nationally does not assist clinicians who may encounter this relatively rare, but serious condition. (4) Despite spending 10 hours in A&E and displaying increasing signs of confusion he was seen to be trying to get of his hospital bed which created a risk of falls, no (5) assessment of the falls risk was carried out. In consequence the receiving ward J27 at St James’s University Hospital, Leeds were not forewarned of the risk of falls. He fell from his hospital bed within approximately 10 minutes of being placed in a side room on his own.

We have considered the contents of your report very carefully and our response is set out below. (a) Transfer of patients

The Trust accepts that Mr Theodossiadis did not have a nurse escort when he was transferred to St James’s Hospital. This would have facilitated a handover of care to the Ward J27 nursing team, including the fact that the patient was at risk of falls. Given the large volumes of patients within both Emergency Departments across the city, it is sometimes not possible or practicable for a nurse to personally escort patients for a cross-city transfer. To do so would deplete the department of an experienced nurse for over an hour, with the potential to compromise care of other patients waiting for treatment. Instead, patients will be handed over to the care of the Yorkshire Ambulance Service who will facilitate safe transfer. For transfers within the same hospital, a now improving staff position means that, wherever possible, the patient will be accompanied to the new ward or clinical area by a member of the ED staff so that a direct handover can be facilitated. For cross-city transfers we must ensure a robust handover of care between nursing staff in the ED and on the receiving ward. This may take the form of a telephone conversation but this should always be accompanied by a written handover document. Currently in the Emergency Department this takes the form of a written document that is then scanned into the electronic patient record (PPM+). The Trust is currently trialling a stand-alone electronic transfer document and it is anticipated that this will be rolled out to all areas of the Trust in due course. The Trust is working towards 100% compliance with use of the transfer document and a rolling audit programme has been taking place for over 12 months to monitor progress. The latest audit figures are encouraging but the Trust recognises that this improvement must be sustained and therefore the process of regular audit will continue. In addition, we are

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seeking an understanding with YAS that they will not accept patients for transfer without a handover document which clearly records the patient’s falls risk. (b) Lumbar puncture

The Trust notes the Coroner’s concerns regarding the need for lumbar puncture. It is recognised that whilst there is national guidance on the indications and timing of lumbar puncture, practice is varied throughout the country. This may be due to a number of factors:
1. Lumbar puncture is a diagnostic test rather than a treatment. As in the case of Mr Theodossiadis, antibiotics were administered shortly after he attended the Emergency Department in line with Trust and national guidance. In other words, treatment was commenced as soon as the team were suspicious of a serious pathology such as sepsis or meningitis. Had a lumbar puncture been carried out first and the results awaited, his life-saving treatment would have been delayed.
2. In this context, the main purposes of the lumbar puncture are to confirm the diagnosis of meningitis, to differentiate between bacterial and viral meningitis, and to guide antibiotic therapy later in treatment. Lumbar puncture can be a painful procedure and is difficult to carry out if the patient is confused or restless. It is a sterile procedure which requires an experienced practitioner to carry it out safely. In a busy emergency department this can be a logistical challenge. If the procedure is delayed, its potential benefits begin to diminish as treatment has already commenced and the chances of culturing a specific organism are reduced.
3. Lumbar puncture is not without risk, with serious complications well recognised. It is contraindicated where there is evidence of coagulopathy or raised intracranial pressure. In practice this means that an unwell patient with possible meningitis will require blood tests and a brain CT scan reported by a radiologist prior to the lumbar puncture being carried out. These require some time to be performed and the results then processed, which again in the context of a busy emergency department will lessen the value of the test being carried out at a later point.

However, the Trust does recognise the potential value of an early lumbar puncture (LP) and is endeavouring to provide this diagnostic test where possible. Specifically, a lumbar puncture may allow antibiotic therapy to be rationalised, with broad spectrum treatment being replaced with more specific antibiotics. As such the Trust has developed a standard operating procedure (SOP) with the aim of carrying out a lumbar puncture within one hour wherever possible. At St James’s University Hospital during daytime hours (8am-8pm), the patient will be transferred to the Same Day Emergency Care (SDEC) unit adjacent to the Emergency Department where the LP will be carried out by a medical registrar or Advanced Practitioner. SDEC is a more suitable environment for the LP to be carried out as it is a less congested and more private area where sterility can be more easily maintained for the procedure to be carried out safely. The SOP should mean that patients with suspected

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meningitis spend much less time in the Emergency Department and can have the lumbar puncture performed by an experienced practitioner in a timely fashion. It is hoped that in due course the service will be available in the St James’s SDEC 24 hours per day. Further consideration is being given to how a similar arrangement could be provided at the LGI site. (c) Patient falls

It is recognised that the Emergency Department is a high risk area for patient falls as many attenders are frail or have pathology that increases their risk. This of course includes patients such as Mr Theodossiadis who are confused because of infection or intracranial pathology. The Trust would like to reassure the Coroner that it takes the risks of falls within the Emergency Department very seriously. All patients within the department should have a falls assessment recorded. As in the case of the handover document, compliance is continuously audited. The latest audit figures demonstrate excellent compliance with the tool, but the department recognises that this must be sustained to prevent future harm to patients. I can confirm that Mr Theodossiadis did have a falls risk assessment completed at 13.14 by the assessment nurse which was entered on to the ED electronic patient record Symphony. He was not deemed to be a falls risk. However when he later became more confused, his assessment should have been repeated. The senior members of the ED nursing team fully recognise the need for repeated assessments when the patient’s condition changes and are working hard to ensure that this practice is embedded within the department. We are monitoring and auditing compliance regarding safety and dignity checks within the department on a daily basis. This includes identifying, risk assessing and monitoring concerns for patients who are at risk, including falls. We have improved our education and understanding of patient risk across the department regarding falls and the importance of rapid and correct assessment of patients on arrival, and the on-going assessment during their stay in ED. The risk of patient falls is continuously highlighted within the Emergency Department. Staff have regular safety huddles where vulnerable patients are discussed. In addition, dedicated ‘falls awareness’ boards have been placed throughout the departments to raise staff awareness and promote best practice. Practical initiatives that have been implemented include the provision of yellow socks for patients at risk of falls to provide a clear visual cue for staff. In addition, we now request additional Clinical Support Worker bank shifts to meet enhanced care needs of our vulnerable patients. In the event that a fall incident does occur, all falls are reported on the Trust’s incident reporting system Datix and a root cause analysis (RCA) is carried out for each case to identify learning points. The Head of Nursing for the Emergency Department reports directly

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to the Executive Team including the Chief Medical Officer and Chief Nurse at the Weekly Quality Meeting for assurance. She reports on a number of key metrics including falls within the department. Thank you for bringing these matters to my attention. I do hope that this response has assured you that the Trust has given careful consideration to the matters of concern you have raised. If I can be of any further assistance please do not hesitate to contact me. Kind regards

OneMedical Group

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Disputed

OneMedical Group disputes that their receptionist training or its frequency was inadequate, stating the incident was isolated and existing annual training already emphasizes eliciting patient information. They believe their training frequency is appropriate and audits show this is not a recurring issue. (AI summary)

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Dear Mr McLoughlin I am writing to you in response to your Regulation 28 report dated 3 December 2021, following the inquest into the death of Alexander Theodossiadis, which you conducted over the course of two days on 17 and 30 November 2021. First, and on behalf of all the staff at One Medical Group, I would like to express my deepest condolences to Alex's family. It was clear from all that was said at the inquest that Alex was a kind, creative individual with a bright future in the music industry ahead of him, and that he was well- loved by many friends and family. We were all deeply saddened by his tragic death. Your report raises two matters that cause you concern and I shall take each in turn. (1) The Inquest heard evidence that when Mr Theodossiadis sought an appointment with a GP he was only able to get one in three weeks’ time. He did not venture any details of his symptoms. Nor, however, did the GP's receptionist probe to obtain any information which would help to assess the urgency of the situation or the priority to be given to his request. Within six days of this telephone call, Mr Theodossiadis was irretrievably overwhelmed with a meningitis infection. One Medical Group appreciates that it can be difficult for individuals to navigate health services to secure appropriate assistance, particularly in the case of a usually young and fit man who hasn't had previous contact with health services, and who is new to a geographical area. One Medical Group notes that you heard evidence that Alex had not previously had cause to interact with health services as an adult, and that when he registered with the GP practice on 16 January 2020 he had likely not been registered with a GP for some years before then. You were provided with a transcript of the telephone call with the GP receptionist on Monday 20 January 2020 and heard evidence that Alex was advised that urgent appointments were made available at 08:00 each morning if required. Alex was therefore provided with appropriate advice in order to secure an urgent appointment should he have felt this was necessary. You found that there was no reliable evidence that Alex made any further efforts to secure an appointment with a GP after this time until he attended the Walk in Centre at 8am on Friday 24 January 2020. You heard evidence from , Head of Patient Safety and Quality, that she had listened to the recording of the call between Alex and the GP receptionist and that it was a "very

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E: enquiries@onemedicalgroup.co.uk onemedicalgroup.co.uk friendly" conversation in which Alex did not convey any urgency about the need for an appointment. This is consistent with your finding that, at the point Alex spoke to the GP receptionist, all involved (including Alex) felt he was suffering from flu like symptoms and did not consider it necessary to press the GP for an urgent appointment or to take him elsewhere to be cared for. On the balance of probabilities, therefore had the receptionist probed to obtain further information she would likely have concluded that Alex did not require an urgent appointment. You heard evidence from various medical practitioners that meningitis can appear very swiftly; "within hours" and you accepted that, on the balance of probabilities, Alex was not displaying any relevant meningitis symptoms other than a headache when he was reviewed by ANP

at 8am on Friday 24 January 2021. It is therefore unlikely that Alex was suffering any red flag symptoms four days earlier, on 20 January 2021, when he spoke to the GP receptionist. It is likely therefore that further probing by the GP receptionist would not have resulted in Alex reporting symptoms that would have necessitated an urgent appointment. When One Medical Group heard of Alex's death, it investigated Alex's contacts with the service and immediately recognised that its GP receptionist should have asked for more information regarding the need for the appointment in accordance with One Medical Group's protocol. One Medical Group apologised to Alex's family that this did not happen. The receptionist was no longer employed by One Medical Group and so we were unable to ascertain why she failed to probe on this occasion. She was trained to do so (please see below) and the expectation of the organisation was that she would question every patient regarding their need for an appointment. We are regretfully unable to say why this did not happen on this occasion. One Medical Group takes its learning obligations extremely seriously and you heard evidence from that, since Alex's death, refresher red flag training has been undertaken with all GP receptionists and non-clinical staff. In addition, an audit of telephone calls to the GP Practice was undertaken from September – November 2021. This audit found that all calls were handled in a friendly and professional manner, and reception staff asked appropriate questions to ascertain the urgency of the appointment i.e. appropriate probing occurred. You also heard evidence from

that in mid-2020 more receptionists were employed by the GP practice in order to cope with pandemic-related additional demand and the intention is for these employees to remain in their role post-pandemic. (2) GP receptionists must strike a difficult balance between respecting medical confidence and obtaining sufficient information to enable a judgement to be made in relation to access to medical help. In the case of fast-moving medical conditions such as meningitis afflicting otherwise healthy young people the Inquest heard concerns that refresher training was regularly required but may not be provided with sufficient frequency to maintain vigilance at this important interface between patients and clinicians. OneMedical Group has no recollection of any concerns being raised at the Inquest regarding the frequency with which refresher training (either specifically for sepsis and meningitis, or training in general) was provided to non-clinical staff. Had this issue been raised, would have been able to provide additional evidence. In any event, we are able to respond as follows:

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E: enquiries@onemedicalgroup.co.uk onemedicalgroup.co.uk No regulator or advisory body provides guidance on the content or frequency of mandatory training for GP receptionists or non-clinical staff (or indeed for any member of a GP Practice administrative team). As noted by the CQC: "ultimately, the practice is responsible for determining what mandatory and additional training staff need and how this is delivered".1 One Medical Group is acutely aware of the importance of appropriate training and has implemented a rigorous training programme. As explained in the letter dated 13 August 2020 from

, Director of Professions at One Medical Group (pages A.95 – A.98 of the inquest bundle), NHS England identified in the 2016 'GP Forward View' Guidance2 that training for reception and non-clinical staff was a "high impact" action. As a result of this 2016 Guidance, One Medical Group developed and implemented bespoke training for its reception and non-clinical staff. Staff training is a key line of enquiry considered by the CQC during any inspection and it is of note that during their most recent inspection of the GP Practice (15 February 2019) the CQC found3:
1. "All staff received up-to-date safeguarding and safety training appropriate to their role. They knew how to identify and report concerns."
2. "There was an effective induction system for temporary staff tailored to their role. This included a mandatory three-day corporate induction prior to starting with the organisation. The corporate induction covered all mandatory training including basic life support."
3. "Staff were suitably trained in emergency procedures."
4. "The practice understood the learning needs of staff and provided protected time and training to meet them. Up-to-date records of skills, qualifications and training were maintained. Staff were encouraged and given opportunities to develop. At the time of our inspection a number of staff were being supported by the practice to complete additional training."
5. "The practice provided staff with ongoing support. There was an induction programme for new staff. This included a mandatory three-day corporate induction prior to starting with the organisation. The corporate induction covered all mandatory training including basic life support."
6. "The practice had plans in place and had trained staff for major incidents." 1 https://www.cqc.org.uk/guidance-providers/gps/gp-mythbuster-70-mandatory-training considerations-general-practice 2 https://www.england.nhs.uk/wp-content/uploads/2016/04/gpfv.pdf 3 https://api.cqc.org.uk/public/v1/reports/5b8d65d6-1ab9-495a-a0ae 42378bc9be86?20210116092739

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E: enquiries@onemedicalgroup.co.uk onemedicalgroup.co.uk The CQC report also contained a quote from a patient commenting that "The reception staff are great and welcoming and very approachable". You heard evidence from that GP receptionists and non-clinical staff have "red flag" training whereby they must demonstrate knowledge of various "red flag" symptoms necessitating further follow up. provided the example that if a patient mentioned chest pain then a receptionist is trained to get immediate advice from a clinician and then advise the patient to call 999 or to attend the GP practice urgently (depending on the clinician's preliminary view). You also heard evidence that GP receptionists and non-clinical staff are trained to identify vulnerable patients who may struggle to convey their symptoms and provided the example of a patient with dementia requiring additional assistance. told you that the training provided is interactive and contains lots of scenarios. In the letter dated 13 August 2020 from , it was explained that the training includes group discussions, case-based reviews, PowerPoint presentations and short educational video clips. Staff understanding is reviewed through an assessment following the training session. If a staff member failed to show sufficient understanding, they would be required to re-attend the training. You were provided with a copy of the training presentation and assessment sheets for both red flags and sepsis recognition for non-clinical staff. The final slide of the training presentation (at page A.111 of the bundle) is as follows: "- What should you do if you suspect a patient has sepsis? YOU MUST BOOK THE PATIENT TO BE SEEN BY A CLINICAN AS SOON AS POSSIBLE (TODAY!!) AND INFORM THE CLINICAL TEAM IMMEDIATELY HOWEVER, IF THE PATIENT REPORTS ANY OF THE FOLLOWING – YOU MUST CALL AN AMBULANCE…
- CHEST PAIN / IRREGULAR HEART BEAT
- DIFFICULTY BREATHING
- SOMEONE TELLS YOU THE PATIENT IS CONFUSED (AND ISN'T USUALLY) OR IS DIFFICULT TO WAKE Always speak to a clinician if you are unsure……!" It is therefore apparent that, during the training, significant emphasis is placed on the relevant red flag symptoms for meningitis and other conditions and that non-clinical staff are required to err on the side of caution if they have any concerns. One Medical Group considers the training is comprehensive and thorough and notes that no concerns have been raised about the content of the training provided. You heard evidence that the training for non-clinical staff is refreshed on an annual basis and One Medical Group strongly disagrees with your suggestion in the PFD Report that refresher training was not provided with sufficient frequency to maintain vigilance. As stated above, there is no CQC or any

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E: enquiries@onemedicalgroup.co.uk onemedicalgroup.co.uk other guidance on the frequency of training for GP receptionists and non-clinical staff, however it is of note that Practice Index, the UK's leading provider of support and services to GP Practice Managers, recommends that sepsis training is undertaken annually for all staff4. Indeed, of the 18 different training areas identified by this organisation for all GP members of staff, no one area is recommended to be repeated more frequently than annually. One Medical Group therefore has no doubt that the frequency of training of non-clinical staff is appropriate and in line with GP practices across the country. The receptionist who took Alex's call had received sepsis training six months before taking Alex's call. She had demonstrated a high level of understanding of the training and increased frequency of training is unlikely to have resulted in the receptionist having had any more recent training prior to the relevant date. One Medical Group believes that the receptionist's failure to probe on this occasion was likely an isolated circumstance and, as set out above, audits have shown that this is not a recurring issue. The annual training provided to reception staff emphasises the need to elicit information from all patients in order to establish the urgency of their need for an appointment. I would like to take the opportunity to assure you, and Alex's family, that One Medical Group seeks to learn from all untoward incidents and absolutely recognises that Alex's death was the most serious type of such incidents. As outlined in the evidence of during the inquest, One Medical Group has already taken learning from Alex's extremely sad death and will continue to do so. Again, I send my deepest condolences to Alex's family.

Department of Health and Social Care Central Government

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Noted

The Department of Health and Social Care notes existing government funding and plans for improving general practice access and refers to actions taken by the relevant Trust, which completed all recommendations by November 2021. It also notes that NICE is updating its meningitis guideline to include those aged 16 and over. (AI summary)

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Dear Mr Mcloughlin, Thank you for your letter of 3 December 2021 to the then Secretary of State, Sajid Javid, about the death of Alexander Theodossiadis. I am replying as Minister with responsibility for Secondary care and thank you for the additional time allowed. Firstly, I would like to say how deeply saddened I was to read of the circumstances of Mr Theodossiadis' death. I can appreciate how distressing his death must be for his parents and those who knew and loved him, and I offer my heartfelt condolences. It is vital that we take the learnings from what happened to prevent future deaths and improve the NHS. In preparing this response, Departmental officials have made enquiries with NHS England, the National Institute for Health and Care Excellence (NICE), as well as the relevant regulation in this case, the Care Quality Commission. General practice is the cornerstone of our NHS and the Government is committed to helping staff deliver for patients. We knew before the pandemic that general practices were under pressure and that patients were finding it difficult to access services. That is why, in 2020, we announced a £1.5 billion funding to create an additional 50 million general practice appointments by 2024, by increasing and diversifying the workforce. In recognition of how challenging the past two years hav~ been for general practices we made an additional £520 million available to improve access and expand general practice capacity during the pandemic, and in October 2021 we published our plan1 for improving access for patients and supporting general practice. The plan included actions to increase and optimise capacity, address variation and encourage good practice and improve communication with the public. One key aspect included in the plan was putting in place arrangements that enabled all general practices to use Microsoft Teams telephone functionality for outbound calls, freeing up lines for incoming calls. The longer-term aim is to drive the adoption of cloud-based telephony across all practices which will bring benefits that support practices to improve call handling and support patients to get more timely access to appointments. I am incredibly grateful for the contribution of GPs and their teams over the last two years, who stepped up to deliver our world-leading vaccination programme while still providing exemplary care for their patients during a pandemic. However, we know that general practices are very busy and remain under huge pressure. General practice appointment numbers are above pre-pandemic levels, excluding appointments for Covid-19 vaccinations, there were on 1 https://www.england.nhs.uk/coronavirus/wp-content/uploads/sites/52/2021/10/BW999-our-plan-for- improving-access-and-supporting-general-practice-oct-21.pdf

average 1.30 million general practice appointments per working day in June 2022, a 6.0% increase from June 2021 (1.22 million). The proportion of face-to-face appointments have also steadily increased from a low point of 46.8% in April 2020 to 64.8% in June 2022. As we emerge from the pandemic response, it is vital that Government continues to monitor and assess how best to support general practice as we have done throughout the pandemic to provide the best possible care for patients. Good access to general practice services is not just about getting a timely appointment, it is also about access to the right person, providing the right care, in the right place at the right time. There have been big changes to the way that much of healthcare operates over the last two years, and general practices have adapted and changed their ways ofworking to continue providing vital services to their communities. One key change has been the wider adoption of remote triage approaches - the process by which patients contacting their general practice are assessed before an appointment is made, so that they are able to access the most appropriate support. Triage will continue to improve and offer long term benefits for patients and practices. NHS England have commissioned an independent evaluation to understand the impact on staff, patients and the wider health and care system of using digital tools and triage approaches in general practice to inform its long-term strategy. Under general practice contract arrangements, it is ultimately the responsibility of practices/contract holders to determine what training staff need and ensure that their staff are appropriately trained to a level that keeps staff safe and meets the needs of patients using the service. The British Medical Association has guidance to help general practitioners and practice managers make informed decisions about what mandatory and statutory training general practice staff should do. The regulator, the Care Quality Commission is the· appropriate body that considers whether practice staff have the right qualifications, skills and knowledge and experience to do their job, how the practice identifies the learning needs of staff, and whether they have adequate training to meet the learning needs. The 2016 General Practice Forward View strategy2 provided support for practices to build the capacity and capabilities required to meet patients' needs. As part of the GP Forward View, the five-year General Practice Development Programme was established. It included total funds of £45 million for allocation by Clinical Commissioning Groups to general practices for training of reception and clerical staff to undertake active signposting and document management. The active signposting training included an expectation for receptionists to be skilled and confident in sensitively ascertaining the nature of the patient's need and exploring with them safe and appropriate options, including sources of advice and support outside the practice as well as within. Further features of the signposting training includ~d a focus on recognising red flag symptoms which require urgent medical attention and skills development to ensure staff are confident in communicating care options. The NHS Long Term Plan. published in 20193, sets out further ambitions for general practice and builds on the ambitions in the GP Forward View. NHS England (NHSE) is continuing to provide support to practices working in the most challenging circumstances via their Accelerate Access Improvement Programme. This programme has been supporting practices to develop tailored improvement plans, including making appropriate use of digital tools, matching capacity to demand and making best use of multidisciplinary teams to improve access for patients 2 https://www.england.nhs.uk/wp-content/uploads/2016/04/gpfv.pdf 3 https://www.longtermplan.nhs.uk/

I understand from the local NHS Leeds Clinical Commissioning Group (CCG), which from 1 July 2022, became part of the NHS West Yorkshire Integrated Care Board (ICB) that it will , continue to review the access arrangements for the particular general practice and implement learning from the incident and other patient feedback in relation to obtaining timely appointments. The ICB is working on improving care access and has established a steering group to review patient pathways and the training of receptionists in care navigation, including integration measures with urgent care services. The ICB is reviewing the recording of incidents to ensure mechanisms to share learning are implemented to improve quality of care. The lCB is also prioritising investment in training for practice staff on red flag symptoms such as meningitis and sepsis. · With regard to the issues that you raise related to the treatment of Mr. Theodossiadis in the hospital, my officials have informed me that Leeds Teaching Hospital NHS Trust has conducted a serious incident report. As a result, a root cause analysis meeting was undertaken 3 days after the incident, which had considered the clinical care of the patient in the emergency department, including the decision around undertaking a lumbar puncture; the organisational issues around the CT; handover care; and the management of the patient by the receiving ward, including falls assessment. · The route cause analysis identified areas for action in that handover and transfer communication be improved to meet the standard of existing Trust's policy, as well as the introduction of a digital handover tool to supplement telephone communications, and to address the mismatch between Trust's meningitis policy and actual practise as regarding timing of lumbar puncture. You may wish to know that all actions and recommendations were undertaken in line with the target dates, and all by November 2021. I ·am also aware of the Trust's response to your report, which has considered the transfer of patients and improvements of transfer documents, the developments of standard operating . procedures, including lumbar puncture, and patient fall and improvements to education and assessment with monitoring of compliance. More generally, you may wish to know that the National Institute for Health and Care Excellence (NICE) guidance on delirium (CG103)4, which covers diagnosing and treating delirium in people aged 18 and over in hospital, as well as identifying people at risk of developing delirium and preventing onset, would be applicable in this case. Moreover, NICE's guideline on meningitis (bacterial) and meningococcal septicaemia in under 16 (CG102)5, includes a section on performing lumbar puncture and interpreting cerebrospinal parameters for suspected bacterial meningitis, however NICE have not published a guideline on meningitis in adults. NICE is currently in the process of updating CG102 and have extended the scope to include people aged 16 and over. I hope this response is helpful. Thank you for bringing these concerns to my attention.

Report sections

Investigation and inquest

On Thursday 6th February 2020 I commenced an investigation into the death of Alexander George Theodossiadis, aged 25. The investigation concluded at the end of the Inquest on Friday 3rd December 2021. The conclusion of the Inquest was a narrative based upon the cause of death of 1 (a} Disseminated Sepsis 1 (b} Streptococcus Pneumoniae Meningitis and 2) Subdural Haemorrhage.

Circumstances of the death

Alexander George Theodossiadis aged 25 was unable to get a GP appointment for some three weeks when he telephoned the GP Surgery on 20th January 2020. He attended a walk-in centre on 24th January 2020 where he was examined and diagnosed with a viral infection. The following day his flat mate took him to A&E where he was admitted and treated for bacterial meningitis. Later the same day he was transferred to another hospital but arrived without a written handover. Within minutes of being placed in a side cubicle in a confused state, he fell from the hospital bed and sustained a head injury. Within a short time, he lost consciousness. His condition deteriorated markedly due to a combination of meningitis infection and a bleed on his brain. He died in hospital on 28th January 2020 after active treatment was withdrawn.

Copies sent to

1) Professor and Dr2) NHS England, NHS England, PO Box 16738, Redditch, B97 9PT3) The Light Surgery, Balcony Level, The Light, The Headrow, Leeds, LS1 8TL1) The Yorkshire Post2) , Bauer Media3) , Press Association

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Report details

Reference: 2021-0412
Coroner: Kevin McLoughlin
Coroner area: West Yorkshire (Eastern)

Responses identified

Responses identified 4 of 3

All listed responses identified

Sent to

Leeds Teaching Hospitals NHS Foundation Trust

One Medical Group

Department of Health

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