St George's University Hospitals NHS Foundation Trust
NHS / Health Body
Action Taken
The Trust has amended Appendix 1 of the Confidentiality Code of Conduct policy to enable staff to leave telephone messages for patients in urgent and emergency situations, has disseminated the learning from this case throughout Cardiology services, and will report to the next Patient Safety and Quality Committee meeting. (AI summary)
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Dear Ma'am Re: The late Ms Ivanika Olivari am writing in response to the Prevention of Future Deaths report that you issued jointly to St. George's University Hospitals NHS Foundation Trust; the General Medical Council and the Secretary of State for Health and Social Care following the inquest touching the death of Ms. Ivanika Olivari which took place on 19 October 2017 and 21 February 2018. note that the matters of relevance to St George's are set out at paragraphs 1 5 under "Coroner's Concerns" For ease of reference, these concerns are: That doctors should leave messages on answerphones for patients to make contact with them in urgent and emergency situations That doctors should attempt to contact patients via all contact phone numbers that have access to for patients in urgent and emergency situations That in urgent and emergency situations risk to life should be considered the priority That SGH hospital guidelines in relation to such matters should be updated and amended to reiiect the above where needed: That SGH should ensure that all relevant staff have their training updated in a prompt and auditable fashion to reflect the concerns raised above: The relevant Trust document that covers communications with patients is the Trust's Confidentiality Code of Conduct which falls within the remit of the Information Governance office, with the Executive sponsor being by Dr Mark Hamilton in his role as Excellence in specialist and community healthcare they policy
Associate Medical Director and Caldicott Guardian. The policy applies to all staff and the current version of this document was issued in March 2017 with a review date set for March 2019. The relevant section of the policy which makes specific reference to contacting patients by telephone is within Appendix 1 of the document The guidance given to staff in the scenario where a phone call is not answered or where an answerphone kicks in is to ring back There is specific instruction to staff not to leave a message on an answerphone: The reason for this instruction was to ensure that messages to call back a clinic or a clinician does not inadvertently compromise the privacy of a patient should the message be picked up by an unintended recipient. However; in light of the concerns you raised in the PFD report, we have made immediate changes to the guidance in Appendix relating to leaving telephone messages, as follows: Contacting patients by phone Where the patient does not answer the telephone and there is no answerphone facility, you should make attempts to ring back Such attempts should be noted in the patient's notes or logged elsewhere, with dates and times, wherever possible. Where the call triggers an answering message with a facility to leave messages; staff may leave a brief message requesting a call back; if the reason for ringing the patient is not urgent Messages must be suitably worded so as not to divulge any personal data as defined in section 3.1 of this policy. In an urgent or emergency situation, staff must leave a brief message requesting a call back; being careful not to divulge any personal data. In an urgent or emergency situation, staff should make further attempts to contact the patient via any other contact phone numbers that they have access to for these patients In an urgent or emergency situation; the risk to life should be prioritised and attempt made to leave an appropriately worded message for the patient to contact the team caring for the patient We hope you will agree that the above change in the guidance now given to staff has fully taken on board the concerns you raised in paragraphs 1 3 In respect of paragraph 4, as explained above, Appendix of the Confidentiality Code of Conduct policy has been amended to reflect the concerns you raised to enable staff to leave telephone messages for patients in urgent and emergency situations Having to review and amend Appendix 1 of the policy has presented an opportunity for the Information Governance office to forward the scheduled review date of the whole policy document to reflect the changes in new General Data Protection Regulations The updated policy will go through the relevant policy stages and will be published by autumn of this year: In the meantime; the updated Appendix 1, together with the learning from this case, has been disseminated throughout Cardiology services_ and is due to be reported to the next Patient Safety and Quality Committee meeting in May and communicated to the wider organisation via the communications department thereafter Excellence in specialist and community healthcare every bring the
The changes in the policy will also be highlighted at the Information Governance Committee meetings and in all Information Governance training sessions A link to the policy will be easily available to all staff through the Information Governance intranet pages. hope; with these measures, that you are reassured that the matters of concern that you raised subsequent to the inquest have been taken very seriously by the trust and that we have taken immediate action to ensure that the policy is updated to address your concerns and all staff are made aware of the change in guidance in relation to leaving telephone messages for patients in urgent and emergency situations_ Please do not hesitate to contact me if | can be of further assistance or if you have any residual concerns
Associate Medical Director and Caldicott Guardian. The policy applies to all staff and the current version of this document was issued in March 2017 with a review date set for March 2019. The relevant section of the policy which makes specific reference to contacting patients by telephone is within Appendix 1 of the document The guidance given to staff in the scenario where a phone call is not answered or where an answerphone kicks in is to ring back There is specific instruction to staff not to leave a message on an answerphone: The reason for this instruction was to ensure that messages to call back a clinic or a clinician does not inadvertently compromise the privacy of a patient should the message be picked up by an unintended recipient. However; in light of the concerns you raised in the PFD report, we have made immediate changes to the guidance in Appendix relating to leaving telephone messages, as follows: Contacting patients by phone Where the patient does not answer the telephone and there is no answerphone facility, you should make attempts to ring back Such attempts should be noted in the patient's notes or logged elsewhere, with dates and times, wherever possible. Where the call triggers an answering message with a facility to leave messages; staff may leave a brief message requesting a call back; if the reason for ringing the patient is not urgent Messages must be suitably worded so as not to divulge any personal data as defined in section 3.1 of this policy. In an urgent or emergency situation, staff must leave a brief message requesting a call back; being careful not to divulge any personal data. In an urgent or emergency situation, staff should make further attempts to contact the patient via any other contact phone numbers that they have access to for these patients In an urgent or emergency situation; the risk to life should be prioritised and attempt made to leave an appropriately worded message for the patient to contact the team caring for the patient We hope you will agree that the above change in the guidance now given to staff has fully taken on board the concerns you raised in paragraphs 1 3 In respect of paragraph 4, as explained above, Appendix of the Confidentiality Code of Conduct policy has been amended to reflect the concerns you raised to enable staff to leave telephone messages for patients in urgent and emergency situations Having to review and amend Appendix 1 of the policy has presented an opportunity for the Information Governance office to forward the scheduled review date of the whole policy document to reflect the changes in new General Data Protection Regulations The updated policy will go through the relevant policy stages and will be published by autumn of this year: In the meantime; the updated Appendix 1, together with the learning from this case, has been disseminated throughout Cardiology services_ and is due to be reported to the next Patient Safety and Quality Committee meeting in May and communicated to the wider organisation via the communications department thereafter Excellence in specialist and community healthcare every bring the
The changes in the policy will also be highlighted at the Information Governance Committee meetings and in all Information Governance training sessions A link to the policy will be easily available to all staff through the Information Governance intranet pages. hope; with these measures, that you are reassured that the matters of concern that you raised subsequent to the inquest have been taken very seriously by the trust and that we have taken immediate action to ensure that the policy is updated to address your concerns and all staff are made aware of the change in guidance in relation to leaving telephone messages for patients in urgent and emergency situations_ Please do not hesitate to contact me if | can be of further assistance or if you have any residual concerns