Cyril Cheetham

Coroner's concerns

AI summary

The "Alternative to Transfer" service for care homes, designed to reduce ambulance calls, introduces an additional triage layer that may delay admissions, yet lacks proper audit for adverse outcomes or deaths.

View full coroner's concerns

The central issue in this investigation was the telephone discussion (transcribed) between Mastercall and own GP as to who would attend that day.

Mastercall had already accepted that one of its GPs would attend that day, following clinical triage at about 09.00hrs and advised the care home. However, later that morning Mastercall determined to change that decision because Mr Cheetham’s presentation did not fit the criteria for the ‘Alternative to Transfer’ (ATT) service provided by Mastercall. Primarily that he was not at risk of admission. In the opinion of the Mastercall clinician it was the own GPs responsibility to attend. That was accepted, eventually, by the own GP who determined that a same day visit was not necessary and stated he would attend the following day.

The matter of concern arises from the ATT service provided by Mastercall. The evidence was that this service was developed by Mastercall, in the Northwest circa 2013, and has since been adopted nationally.

In exploring the development and use of ATT with the Medical Director of Mastercall a number of issues arose.

Issue One It is clear that the service was developed to reduce demand on the ambulance service, to provide an additional layer of access to medical advice for care homes where it is felt on telephone triage that there is a risk of admission. Where a risk of admission exists a Mastercall GP will attend, seemingly on the basis that the patient would likely be seen sooner. If admission is required, then that would be arranged by the attending Mastercalll GP. The aim of ATT is to reduce the number of unnecessary calls to the ambulance services from care homes.

The Medical Director of Mastercall advised that the service had been a success with a 67% diversion rate of ambulances. His evidence was that there was a significant net benefit from the ATT service. He was unable to say what downsides there were or what was the measurement for negative costs. He said he was not aware of any significant adverse outcomes.

The ATT services introduces an additional layer of triage based on a telephone conversation between a clinician at Mastercall and someone at the care home, who may be a carer or a nurse, and may be experienced or inexperienced, rather than that person calling 999. It is of concern to me that this additional layer may result in a delay in admission, which for an elderly patient with likely co-morbidities, will affect their prospects.

It was accepted that there was no audit or research carried out in respect of any deaths arising from delay in admission where the ATT service was used. The net benefit seems to have been calculated by reference to resource savings alone.

I am concerned that the ATT service is being resourced and provided (nationally) without any adequate or true audit of its perceived net benefit, and that its use may be costing lives, either at all or at an unacceptable level.

Issue Two

The inquest highlighted a lack of clarity as to the criteria for the ATT service.

The conversation between Mastercall and the own GP highlighted the ‘grey area’ that exists between a routine (no risk of admission) attendance and a ‘risk of admission’ attendance. It is clear from the events that unfolded that Mr Cheetham clearly was at risk of admission. In my view the lack of clarity resulted in Mr Cheetham not being seen by a GP that afternoon while there was likely no difference in outcome in his case, it is clear that this existence of a ‘grey area’ of responsibility might result in future deaths.

Responses

2 respondents

Dept of Health and Social Care Other

2 Feb 2021 PDF

Noted

The Department of Health and Social Care acknowledges the concerns and states that the planning and commissioning of local health services is the responsibility of CCGs. They note that Stockport CCG has responded and that Mastercall has undertaken to conduct a full audit of the ATT service. (AI summary)

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Dear Mw kslqman , Thank you for your letter of 2 February 2021 to Matt Hancock about the death of Cyril Cheetham: am replying as Minister with responsibility for urgent and emergency care and am grateful for the additional time in which to do so. First; would like to express my condolences to the family of Mr Cheetham: was saddened to read the circumstances of Mr Cheetham's death and the omissions in care identified by your investigation: Clearly, we must take the learnings from Mr Cheetham's death to ensure patients continue to receive the very best care from the NHS. In preparing this response, my officials have made enquiries with NHS England and NHS Improvement (NHSEI): It may be helpful if begin by explaining that the planning and commissioning of local health services in England is the responsibility of clinical commissioning groups (CCGs), which have the knowledge of their local population healthcare needs and can design services to meet those needs: This includes out-of-hours services. It is the responsibility of CCGs to monitor and assure the delivery of services in line with agreed service specifications: am advised that the Stockport CCG has provided a response to you explaining the regular contract monitoring that is in place with Mastercall, the provider of the 'Alterative to Transfer' (ATT) service, and confirming that no significant concerns have been identified by the CCG. am further advised that clear guidance is in place in relation to the patients that meet the criteria for the service and that calls to the service are triaged by senior clinicians. Nevertheless, am pleased to be informed that Mastercall has undertaken to conduct a full audit of the ATT service to ensure it is delivering high-quality, safe services to patients. In May

addition, to provide more immediate assurance, all calls to the ATT service are being reviewed, You may wish to note that in March 2020, the NHS published framework for delivering enhanced health in care homes'_ This set out that people living in care homes should have equity of access to the urgent and emergency care system as people living in their own homes. Every care home should be linked to these teams through single points of access and through sharing care plans and protocols with these teams, including: GP in-hours services; GP extended access services; GP out-of-hours services; NHS 111; Urgent Community Response; and, the local ambulance service. The framework is clear that when hospital admission is indicated, this should be facilitated promptly: Urgent Community Response teams will respond to people with complex health needs who have urgent care need, including the risk of being hospitalised, and will be able to access a response from a skilled team of professionals within two hours to provide the care they need to remain independent The two-hour standard is expected to be in place across England by April 2023. The Enhanced Health in Care Homes requirements have been of vital importance during the COVID-19 pandemic, supporting the organisation and delivery of a coordinated service to care home residents, many of whom are at very high risk of a severe negative impact (directly or indirectly) from COVID-19. 2~ 1617 EDWARD ARGAR MP the-framework-for-enhanced health in-care-homes-v2-0pdf (england nhs uk) very

Stockport Clinical Commissioning Group NHS / Health Body

24 Mar 2021 PDF

Action Taken

Stockport CCG has addressed concerns about the ATT service by agreeing that any visit required following initial telephone assessment will be performed by Mastercall, with exceptions only when a GP expresses a preference. The CCG is working with Mastercall and the wider primary care system to remove a 'grey area' in the service criteria. (AI summary)

View full response

Dear Mr Bridgman

Regulation 28 (PFD) Report - Mr Cyril Cheetham

I refer to your above report dated 2 February 2021 in relation to the above and thank you for contacting NHS Stockport Clinical Commissioning Group (CCG) in this matter. I would like to begin by offering my sincere condolences to the family of Mr Cheetham.

You have raised a number of points of concerns which I will address in order:-

 Lack of Audit re ATT Service

You express concern that the ATT service is being resourced and provided nationally without any adequate or true audit of its perceived net benefit; your concern is that its use may be costing lives, either at all, or at an unacceptable level.

Whilst I am unable to comment on any national evaluation I am able to provide information and reassurance in relation to local evaluation and monitoring of the ATT service in Stockport.

The ATT was set up to provide a dual role:-

(1) To allow Care Homes and ambulance staff access to a clinician as an alternative to transport to the Emergency Department

(2) To allow management of conditions that are time sensitive but may not require admission

The design was to allow access to this resource 24/7.

The services that Mastercall provide for the Stockport population, including ATT are monitored within a process of regular quality review; these reviews are undertaken internally by Mastercall using their Clinical Guardian system, the DATIX risk management system and also by a review of complaints, in addition to regular contract quality reviews. To date there have been no significant concerns raised regarding the ATT service. Whilst I am assured that this review process would highlight any patient risk, I am pleased to note that Mastercall are in the process of undertaking a full audit of the ATT service with the aim of providing rigorous evidence that the service is safe. It is anticipated that the outcome of the audit will be available within 8 weeks.

The ATT service is designed as a tier between GP and hospital services to support ambulance crews who on review of a patient do not believe that hospital admission is required. By contacting this service the crew have access to medical input and advice and can often avoid the need to transfer a patient to the hospital. The service also supports care home patients at risk of hospital admission; for the latter cohort of patients it is generally accepted that Emergency Department (ED) attendance is often very disruptive and so access to the ATT service means that attendance to the ED can be avoided and care provided in the patient’s home environment.

The Service Specifications are rigorous with excellent performance by Mastercall and communications provide clear guidance in relation to which patient cohorts are suitable for their service and which should be directed to 999. Calls into the service are triaged by a senior clinician and I am therefore confident that any inappropriate call to the ATT service from a care home or ambulance crew would be promptly redirected to 999.

Your report and comment in relation to this issue has led to a full audit being undertaken which I am confident will provide reassuring evidence of the benefit of this service. As referred to above it is anticipated that the audit will be complete by mid May 2021. In the meantime I can confirm that Mastercall have already instigated a change to their Clinical Guardian system to review all ATT calls to provide short term assurance whilst the data is developed for the audit.

 Criteria for the ATT Service

Your report also highlights concern that there is a lack of clarity in relation to the criteria for the ATT service and specifically that there appeared to be a ‘grey area’ that exists between a routine (no risk of admission) attendance and a risk of admission attendance. I agree that from the information presented at inquest in this case, it is clear that guidance needed to be re-visited in order to ensure that the service was accessed appropriately and most importantly that patients received the right care in the right service at the right time.

This issue has been addressed through a system wide discussion; essentially the issue as described within your report arose due to a view taken on ‘at risk of admission’. It has therefore been agreed that any visit required following initial ATT telephone assessment will be performed by Mastercall. The only exception to this will be in circumstances where a GP expresses a preference to undertake the visit which must happen on the same day. This process provides assurance that the patient will be seen the same day but does allow the flexibility of the patient’s own GP, who knows the patient best, to remain involved as appropriate.

I will be working with the Deputy Medical Director at Mastercall and also with my colleagues within the wider primary care system; and I am confident that the steps we are taking across the system will remove the ‘grey area’ and any associated risk.

I am satisfied that lessons have been learnt as a result of this case, I am though conscious that we cannot ‘undo’ what happened here and I am sorry that Mr Cheetham’s referral into ATT was not managed as well as it should have been. I hope that his family will be comforted to know that steps have been taken to ensure that other patients do not find themselves in similar circumstances.

I hope the above information is helpful to you but if you do need any further information then please contact me.

Report sections

Investigation and inquest

On 01.03.19 an investigation commenced into the death of Cyril Cheetham who died on 25.02.19.

The death was reported to the Coroner by the Registrar as the original MCCD listed Streptococcal septicaemia at 1a. The investigation concluded on 22.12.20. The conclusion was one of Natural Causes The medical cause of death was 1a) Multiple organ failure 1b) Streptococcal septicaemia 1c) Bronchopneumonia
2) Acute kidney injury

Circumstances of the death

At the time of his death Cyril Cheetham was 91 years of age. He suffered with dementia and was resident at a care home where had lived for some 4 years. Following a fractured hip in 2018 Mr Cheetham could not walk, he required assistance getting in and out of bed, and assistance with personal chores. Once in his wheelchair he was able to mobilise himself around.

In the early hours of 20.02.19 Mr Cheetham was noted to have become unwell. An OOH service was called (Mastercall) who advised analgesia and to contact own GP in the morning. The home contacted own GP practice at about 09.00hrs and were told to call Mastercall. This they did and were advised a GP from Mastercall would call that day. This arrangement was changed following a telephone call between Mastercall and own GP. The outcome of that conversation was that the own GP would attend the next day. That information was not relayed to the care home, who for the remainder of the day anticipated the attendance of a (Mastercall) GP to assess Mr Cheetham.

Cyril Cheetham suffered a deterioration in the early evening of 20.02.20. Mastercall were called and the GP who attended arranged for Mr Cheetham to be admitted to hospital, arriving at about 23.30hrs on 20.02.19. The following morning Mr Cheetham was placed on an end of life pathway. He died on 25.02.19.

The inquest identified a number of omissions in the care of Cyril Cheetham over the course of 20.02.19 by those caring for him. The most significant issue being the nonattendance of a GP that day following the discussion between Mastercall and the own GP, and that the home was not made aware of the change in the plan.

A GP should have attended that day or obtained further information as to Mr Cheetham’s condition prior to making the decision that the matter could wait until the following day.

Evidence was taken from the receiving hospital as to the likely outcome with an earlier admission. The opinion of the consultant was that given Mr Cheetham’s age and other conditions his risk of mortality was very high from the outset out of infection and that it was only possible that an earlier admission may have given him a better chance.

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