Paul Price
Action Planned
The Trust is transitioning to a Docman hybrid mail system for GP correspondence and plans to implement system changes, including an automated phone call system, to improve message recording and forwarding, disputing a specific IT downtime event. (AI summary)
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Dear Mrs Hunt
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
On 20th June 2018 you commenced an investigation into the death of Paul Price. The investigation concluded at the end of the inquest on 18th September 2018. On 4th June 2018 Mr Price was found on the ground outside his accommodation having fallen from a height. He was taken to Queen Elizabeth hospital where he passed away. The conclusion of the Inquest was Open as you were unclear what Mr Price's intentions were. In addition the Inquest identified the following concerns:-
* Paul was seen for a full assessment on 4th May 2018. The summary of that attendance in a letter was not received by the GP until 29th May 2018. In the meantime Paul had attended his GP with ongoing concerns about his mental health and requesting further medication. The delay in receiving critical information about vulnerable patients could put them at risk and result in overprescribing of medication.
* You were told IT systems for Birmingham and Solihull Mental Health Trust and the GP's are incompatible meaning that letters have to be faxed or posted causing further delay.
* A call was made to the Mental Health Team on 1st June 208 raising a concern about Paul's mental health. The caller was told the computer systems were down and the mental health team would call back- they did not call back. There is a concern that staff are not accurately recording information and arranging follow- up.
Chair: Sue Davis, CBE Chief Executive: John Short PALS Patient Advice and Liaison Service Customer Relations Mon - Fri, 8am - 8pm Tel: 0800 953 0045 Text: 07985883 509 Email: pals@bsmhft.nhs.uk Website: www.bsmhft.nhs.uk
POSITIVE ABOUT DISABLED PEOPLE Stonewall DIVERSITY CHAMPION Improving mental health wellbeing
I would like to thank you for bringing these matters to my attention under a Regulation 28 Report and wish to apologise for the failings incurred by the Trust.
1. In relation to the delay in Paul's GP receiving critical information this has highlighted a potential systemic issue that is not localised to one service. We have established Trustwide timescales and targets for the completion of GP letters but have found, on investigation, that across the Trust different Consultants and teams have different local arrangements and that with staff leave and absence, there are variations in capacity to complete these within defined timescales. The Trust has invested heavily in electronic recording and listening devises and the use of hybrid mail and along with a management focus on dealing with team and capacity variations should give us confidence that we have addressed these issues. I would ask if I may, that I write to you in three months to update you on the outcome and progress made to address the concern.
2. With respect to the incompatibility of BSMHFT and GP systems, this is a local issue that is reflected nationally and we have previously written to you about this more general topic. We are, and continue to be of the view that there does need to be a national solution to rapid information sharing between NHS care providers. We have previously written to NHS England (NHSE) about this need, however there is no solution at present, which means that risk remains in our systems. We have worked collaboratively with our local MERIT mental health partners (Birmingham Childrens, D&W, BCP and CWP) to find a local solution to this we do now have a single system in place that allows us to access each other's information electronically. We are also in the process of developing an electronic mail system linking to GP surgeries via Hybrid Mail. This system is called Docman and currently there is a project working group being led by Birmingham Women and Children's NHS Foundation Trust which we have joined. This group is working to implement Docman across all GP surgeries locally and then to develop it as a national system.
3. On the matter of computer systems, staff recording information and following up, we have checked our IT systems and there is no record of unplanned downtime for the 1st June 2018. Any planned downtime tends to be very late into the day and before the start of the morning shift. The failure to pass on the message was a staff error but we are also looking to implement system changes which will support the recording and forwarding of messages. This includes an automated phone call system which will log and audit all phone calls made internally and externally to the Trust. Again I would like to be able to write to you in three months to advise you of our progress in making this system available and implemented across all our hundred plus teams.
Once again, thank you for raising these concerns with me and please do be assured that these have been taken very seriously by the Trust. If you are in agreement with these proposals I will contact you again by 4th February 2019 to provide the necessary assurances that we have provided systemic support to mitigate for the concerns raised by you.
Summarines
On a personal level I would like to inform you that after a second stint as an NHS Chief Executive and six years as Chief Executive at the Trust I am retiring at the end of March 2019. The interview for my replacement will take place in the next two weeks and I am hopeful that we will have in place my successor before I leave. I will ensure that my successor picks up any outstanding issues on their appointment and I will arrange a meeting between you both as part of their induction programme to this challenging role.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
On 20th June 2018 you commenced an investigation into the death of Paul Price. The investigation concluded at the end of the inquest on 18th September 2018. On 4th June 2018 Mr Price was found on the ground outside his accommodation having fallen from a height. He was taken to Queen Elizabeth hospital where he passed away. The conclusion of the Inquest was Open as you were unclear what Mr Price's intentions were. In addition the Inquest identified the following concerns:-
* Paul was seen for a full assessment on 4th May 2018. The summary of that attendance in a letter was not received by the GP until 29th May 2018. In the meantime Paul had attended his GP with ongoing concerns about his mental health and requesting further medication. The delay in receiving critical information about vulnerable patients could put them at risk and result in overprescribing of medication.
* You were told IT systems for Birmingham and Solihull Mental Health Trust and the GP's are incompatible meaning that letters have to be faxed or posted causing further delay.
* A call was made to the Mental Health Team on 1st June 208 raising a concern about Paul's mental health. The caller was told the computer systems were down and the mental health team would call back- they did not call back. There is a concern that staff are not accurately recording information and arranging follow- up.
Chair: Sue Davis, CBE Chief Executive: John Short PALS Patient Advice and Liaison Service Customer Relations Mon - Fri, 8am - 8pm Tel: 0800 953 0045 Text: 07985883 509 Email: pals@bsmhft.nhs.uk Website: www.bsmhft.nhs.uk
POSITIVE ABOUT DISABLED PEOPLE Stonewall DIVERSITY CHAMPION Improving mental health wellbeing
I would like to thank you for bringing these matters to my attention under a Regulation 28 Report and wish to apologise for the failings incurred by the Trust.
1. In relation to the delay in Paul's GP receiving critical information this has highlighted a potential systemic issue that is not localised to one service. We have established Trustwide timescales and targets for the completion of GP letters but have found, on investigation, that across the Trust different Consultants and teams have different local arrangements and that with staff leave and absence, there are variations in capacity to complete these within defined timescales. The Trust has invested heavily in electronic recording and listening devises and the use of hybrid mail and along with a management focus on dealing with team and capacity variations should give us confidence that we have addressed these issues. I would ask if I may, that I write to you in three months to update you on the outcome and progress made to address the concern.
2. With respect to the incompatibility of BSMHFT and GP systems, this is a local issue that is reflected nationally and we have previously written to you about this more general topic. We are, and continue to be of the view that there does need to be a national solution to rapid information sharing between NHS care providers. We have previously written to NHS England (NHSE) about this need, however there is no solution at present, which means that risk remains in our systems. We have worked collaboratively with our local MERIT mental health partners (Birmingham Childrens, D&W, BCP and CWP) to find a local solution to this we do now have a single system in place that allows us to access each other's information electronically. We are also in the process of developing an electronic mail system linking to GP surgeries via Hybrid Mail. This system is called Docman and currently there is a project working group being led by Birmingham Women and Children's NHS Foundation Trust which we have joined. This group is working to implement Docman across all GP surgeries locally and then to develop it as a national system.
3. On the matter of computer systems, staff recording information and following up, we have checked our IT systems and there is no record of unplanned downtime for the 1st June 2018. Any planned downtime tends to be very late into the day and before the start of the morning shift. The failure to pass on the message was a staff error but we are also looking to implement system changes which will support the recording and forwarding of messages. This includes an automated phone call system which will log and audit all phone calls made internally and externally to the Trust. Again I would like to be able to write to you in three months to advise you of our progress in making this system available and implemented across all our hundred plus teams.
Once again, thank you for raising these concerns with me and please do be assured that these have been taken very seriously by the Trust. If you are in agreement with these proposals I will contact you again by 4th February 2019 to provide the necessary assurances that we have provided systemic support to mitigate for the concerns raised by you.
Summarines
On a personal level I would like to inform you that after a second stint as an NHS Chief Executive and six years as Chief Executive at the Trust I am retiring at the end of March 2019. The interview for my replacement will take place in the next two weeks and I am hopeful that we will have in place my successor before I leave. I will ensure that my successor picks up any outstanding issues on their appointment and I will arrange a meeting between you both as part of their induction programme to this challenging role.