Pennine Care NHS Foundation Trust
NHS / Health Body
Action Taken
The Clinical Director for the Borough has established a process that ensures that all new medical trainees receive a presentation regarding the standards expected and process of writing admission/discharge summaries and a senior doctor checks the documentation. Pennine Care NHS Foundation Trust has issued all new trainees with laptops, and documentation review is now incorporated in trainees’ weekly supervision. (AI summary)
View full response
Dear Ms McKenna
I write in response to your Regulation 28 report dated 23rd October 2020 and in respect of the concern you have highlighted after hearing evidence of the inquest of Mr Sean Owen.
Your concern has been reviewed and Pennine Care’s response is outlined below.
Coroners Concern
I heard evidence that there is currently no system in place at Pennine Care NHS Foundation Trust for quality assurance of the Discharge Summary Letters which are sent to General Practitioners when a patient is discharged from Inpatient care. The evidence heard at the inquest and recorded in the clinical records was that Mr Owen’s admission to Hollingworth ward on 6th December 2018 had been precipitated by an overdose; that there were two further incidents of overdose during the admission; that he was changeable in relation to risk, sometimes stating that he wanted to end his own life and at other times denying it and that he presented a significant risk to himself and others if he became non-compliant with medication.
The discharge letter that was sent to Mr Owen’s GP on 6th February 2019 was prepared by a doctor who had little involvement in his care and was not counter checked by a senior clinician. It omitted references to the overdoses and was erroneous in stating that there had been ‘no issues or incidents’ during the admission; that the Deceased ‘never showed any DSH behaviour as an inpatient’ and that ‘we did not see and SH behaviour or expressed thought from Sean during his admission.’ The letter made no reference to the significant risk associated with non-compliance.
Response
Mental Health Services in Heywood, Middleton and Rochdale have reviewed processes since the untimely death of Mr Sean Owen.
The Clinical Director for the Borough has established process that ensures:
• All new medical trainees receive a presentation regarding the standards expected and process of writing admission/discharge summaries.
• During their first month working on the wards all new trainees have their written admission/discharge summaries checked and discussed at the ward round held prior to discharge of the patient. A senior doctor checks the documentation.
• Pennine Care NHS Foundation Trust have issued all new trainees with laptops, with the expectation that the admission/discharge summary starts at the point of admission as a live document that can be added to/updated as appropriate throughout the admission. Therefore this provides a document ready for the discharge ward round for final additions which is then forwarded to the GP.
• Documentation review is now incorporated in trainees’ weekly supervision.
The revised process will be subject to an audit.
The template for the admission is attached.
DX summary.docx
To ensure wider learning, the concerns highlighted and HMR’s response were discussed at the senior medical management team recently. Verbal assurances were received from all other Boroughs across PCFT with regards to consent processes and a plan for the Associate Medical Directors to facilitate a dedicated meeting to discuss and agree sharing best practice.
I trust this response assures you that the Trust has taken your concern seriously and has thoroughly reviewed the issues raised.
I write in response to your Regulation 28 report dated 23rd October 2020 and in respect of the concern you have highlighted after hearing evidence of the inquest of Mr Sean Owen.
Your concern has been reviewed and Pennine Care’s response is outlined below.
Coroners Concern
I heard evidence that there is currently no system in place at Pennine Care NHS Foundation Trust for quality assurance of the Discharge Summary Letters which are sent to General Practitioners when a patient is discharged from Inpatient care. The evidence heard at the inquest and recorded in the clinical records was that Mr Owen’s admission to Hollingworth ward on 6th December 2018 had been precipitated by an overdose; that there were two further incidents of overdose during the admission; that he was changeable in relation to risk, sometimes stating that he wanted to end his own life and at other times denying it and that he presented a significant risk to himself and others if he became non-compliant with medication.
The discharge letter that was sent to Mr Owen’s GP on 6th February 2019 was prepared by a doctor who had little involvement in his care and was not counter checked by a senior clinician. It omitted references to the overdoses and was erroneous in stating that there had been ‘no issues or incidents’ during the admission; that the Deceased ‘never showed any DSH behaviour as an inpatient’ and that ‘we did not see and SH behaviour or expressed thought from Sean during his admission.’ The letter made no reference to the significant risk associated with non-compliance.
Response
Mental Health Services in Heywood, Middleton and Rochdale have reviewed processes since the untimely death of Mr Sean Owen.
The Clinical Director for the Borough has established process that ensures:
• All new medical trainees receive a presentation regarding the standards expected and process of writing admission/discharge summaries.
• During their first month working on the wards all new trainees have their written admission/discharge summaries checked and discussed at the ward round held prior to discharge of the patient. A senior doctor checks the documentation.
• Pennine Care NHS Foundation Trust have issued all new trainees with laptops, with the expectation that the admission/discharge summary starts at the point of admission as a live document that can be added to/updated as appropriate throughout the admission. Therefore this provides a document ready for the discharge ward round for final additions which is then forwarded to the GP.
• Documentation review is now incorporated in trainees’ weekly supervision.
The revised process will be subject to an audit.
The template for the admission is attached.
DX summary.docx
To ensure wider learning, the concerns highlighted and HMR’s response were discussed at the senior medical management team recently. Verbal assurances were received from all other Boroughs across PCFT with regards to consent processes and a plan for the Associate Medical Directors to facilitate a dedicated meeting to discuss and agree sharing best practice.
I trust this response assures you that the Trust has taken your concern seriously and has thoroughly reviewed the issues raised.