Frances Greenhalgh

In the circumstances it is my statutory to report to you: During the Inquest evidence was heard that: - On the 22nd March 2017 the Surgery received a letter by fax message from the RAID Team in relation to a plan of treatment for the deceased which included actions to be taken by the General Practitioner, On the 4th April 2017, 13 following the notification, the General Practitioner had not the RAID Team notification with the deceased's medical records and there was no record of the notification on the computer systems at The Surgery. who no longer works at The Surgery, was not aware of ay systems at The Surgery in relation to the receipt of notifications from Healthcare Professionals or systems in relation to the recording of notifications and information on a patients record so that the information is available to a General Practitioner on the next appointment with the patient: On the 4th April 2017 was unaware of the notification from the RAID Team and there was no evidence that the deceased had received any communication from the General Practitioner after the 22nd March 2017 in relation to the plan agreed with the RAID Team on that date: I request the Senior Partner of The Surgery to conduct a review of the documented protocols and systems relating to the processing and recording of notifications received from Healthcare Professionals, particularly where the notification is received from Healthcare Professional outside The Surgery. The review should consider the training of Healthcare Professionals, including Doctors, and check systems to ensure that any notifications are recorded on the patient notes and on any computerised system available to Healthcare Professionals within The Surgery without delay so that the notification and any plan of treatment are available to Doctor or Healthcare Professional at the next appointment with the patient: Furthermore the notification should trigger contact with the patient, if appropriate, and in any event; if the the agreed plan requires contact, to enable the patient to receive the benefit of treatment and care in accordance with the plan without delay: ACTION SHOULD BE TAKEN In my opinion urgent action should be taken to prevent future deaths ad believe that YOU have the power to take such action duty days put the

YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report; namely by 7u November 2017. 1, the Coroner , may extend period. Your response must contain details of action taken Or proposed to be taken, setting out the timetable action: Otherwise yoU must explain why no action is proposed: COPIES and PUBLICATTON Ihave sent a cOpy of my report to the Chief Coroner ad to the following Interested Persons: - Miss Greenhalgh's sister,
2. Miss Greenhalgh's brother, 3_ Iam also under a duty to send the Chief Coroner a cOpY of your response_ The Chief Coroner may publish either or both in complete or redacted Or summary form: He may send a copY of this report to person who he believes may find it useful or of interest; You may make representations to me; the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. Dated Signed 12th September 2017 Or Alan Peter Walsh_HM Area Coroner the for any