Source · Prevention of Future Deaths

Suzanne Greenwood

Ref: 2015-0370 Date: 9 Oct 2015 Coroner: Alan Walsh Area: Manchester (West) Responses identified: 1 / 1 View PDF

Lack of systems and protocols for contacting patients who miss appointments, informing GPs of non-attendance or discharge, and ensuring continuity of care when patients are lost to follow-up.

Date 9 Oct 2015

56-day deadline 4 Dec 2015 est.

Responses identified 1 of 1

Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary

Lack of systems and protocols for contacting patients who miss appointments, informing GPs of non-attendance or discharge, and ensuring continuity of care when patients are lost to follow-up.

View full coroner's concerns

During the Inquest evidence was heard that Mrs Greenwood had not been seen byl at The Priory Hospital_Altrincham after her last review on the 21st November the the Mrs

2013 prior to her death on the 23r December 2014, She had failed to attend appointments in January 2014 but there had been no contact with her , either by telephone or letter , following her failure to attend appointment on the 16th January 2014. Mrs Greenwood had not been discharged byE following her failure to attend her appointment on the 16" January 2014 and before her death on the 23rd December 2014 but there had been no contact with her for a period exceeding 11 months: iii, had not made any contact with the General Practitioner to confirm Mrs Greenwood's failure to attend her appointments in January 2014 and that she had not been seen after the 21st November 2013, which is a particular concern when an Advanced Nurse Practitioner reduced the medication initially prescribed by which she had the authority to reduce, in circumstances where had not seen Mrs Greenwood since the 21st November 2013. iv There are no systems, either int private practice or in the Priory Hospital, Altrincham to contact patients following failure to attend appointments and to consider the discharge of patients when a patient repeatedly fails to attend appointments over a period of time; There are no timescales with regard to the discharge of patients and no system to contact General Practitioners or other health professionals in relation to the failure to attend appointments, particularly in circumstances where other health professionals are likely to continue to treat patients after missed appointments, including changes in medication: The importance of 'discharge within a reasonable period after a failure to attend appointments is important to enable other health professionals involved in continuing care to be aware of the non-attendance at appointments and the discharge: The fact that there has been no reported failure to attend appointments and no reported discharge would be misleading to other health professionals involved in continuing care; particularly when a patient has not been seen for a period in excess of 12 months and that information would not be available to other health professionals in the absence of information from the Hospital: There is a need for health professionals involved in the continuing care of a patient to be kept informed as to the treatment or non-treatment of the patient at a Hospital when considering further treatment in the community. 2, I request you to consider the above concerns and for bothl and The Priory Hospital, Altrincham to out a review with regard to the following: The systems procedures, policies and protocols in relation to contact with patients who fail to attend appointments: the the carry

The systems, procedures, policies and protocols in relation to patients who repeatedly fail to attend appointments and to consider a final letter to the patient indicating that the patient will be discharged unless there is either contact or an appointment within a defined period, iii: The systems, procedures, policies and protocols in relation to the discharge of patients who repeatedly fail to attend appointments with notification to General Practitioners or other health professionals of the patients failure to attend appointments and their discharge from hospital, The review should consider timescales in relation to discharge when patient has failed to attend appointments for a specific period of time:
iv. The evidence raised concerns that there is a risk that future deaths will occur unless action is taken to review the above issues:

Responses

1 respondent

Priory Group Private Sector

2 Dec 2015 PDF

Action Taken

The Priory Group amended its policy regarding independent doctors, requiring prompt GP contact for missed appointments and detailed discharge letters. The amended policy has been circulated, discussed at meetings, and will be included in a learning bulletin. (AI summary)

View full response

Dear Mr Walsh Re Suzanne Greenwood Deceased Thank you for your letter dated Monday 12 October 2015 in which you enclosed your report to prevent future deaths under paragraph 7, schedule 5 of the Coroners and Justice Act 2009 ad regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. Your letter was addressed tol Manager Director Priory Group Healthcare Division and Consultant Psychiatrist. It is upon their behalf and on behalf of the Priory Group Hlealthcare Division that I reply: You have asked that the following actions are taken:
1. You asked that a review is carried out of the systems, procedures, policies and protocols in relation to contact with patients who fail to attend appointments. Upon receint_of_vour report we undertook a review of this matter It is relevant in this case that is a Consultant Psychiatrist with 'Practising Privileges' meaning that he undertakes his work at Altrincham Hospital as an independent doctor seeing outpatients whilst making use of the facilities at the hospital for example the consulting rooms and IT equipment: A policy is in place which outlines expectations of those doctors who work in this way: H1os: Practising Privileges for Independent Doctors: the Policy

The policy makes it clear that independent doctors should work in accordance with General Medical Council requirements and relevant Priory Healthcare Division policies and procedures: The policy states that a contract must be signed by the applicable Hospital Medical Director ad the particular doctor prior to that person commencing work as an independent doctor. The policy also notes that the independent doctor should avail themselves of supervision and appraisal We have identified that there are policies in place which govern the admission, transfer and discharge of patients. These policies give details of the requirement to communicate in an effective and timely way with General Practitioners and others who may be involved with the patient: As part of our review we identified that the requirement to communicate in an effective and timely way with General Practitioners and others who may be involved with patient needed to be strengthened in Policy H1O5 which as I have stated is the particular policy relevant to independent doctors 2 You asked that a review is carried out of the systems procedures, policies and protocols in relation to patients who repeatedly fail to attend appointments and to consider a final letter to the patient indicating that the patient will be discharged unless there is either contact or an appointment made within a defined period; and 3 That a review is carried out of the systems, procedures; policies and protocols in relation to the discharge of patients who repeatedly fail to attend appointments with notifications to General Practitioners or other relevant health professionals of the patient's failure to attend appointments and their discharge from hospital. The review should consider timescales in relation to discharge when patient has failed to attend appointments for specific period of time In response to 2 and 3 please note that we have given full consideration to these matters and have now made the following requirements explicit in Policy H1os: Practising Privileges for Independent Doctors: That the independent doctor will complete a final letter to_the_patient in those instances where there has been repeated failure to attend appointments either with or without notice been given by the patient: The letter must be copied to other relevant professionals involved in the patients care for example the General Practitioner. The letter should give detail of the patients medication; recommendations for after care and identify the possible actions to be taken in the event of the patient experiencing a crisis. The letter should also identify possible options for the patient to pursue should need more routine assistance in the future and these options could include their General Practitioner andjor re- referring themselves to the independent doctor; That the independent doctor will complete and send a discharge letter to_the_General Practitioner and other relevant professionals after the final contact with the patient in those instances where the patient has failed to attend appointments_ The letter should give detail of the patients medication, the recommendations for after care and as with the first bullet point above identify possible actions to be taken by the General Practitioner should the patient experience future crisis. The letter should be copied to the patient. Prompt telephone contact should be made with the General Practitioner in those instances where there are deeper concerns about the patient: the having they visiting

We have taken the following actions in relation to giving advice to our independent doctors about the requirements and the adjustments outlined above:
1. The amended H105: Practising Privileges for Independent Doctors has been circulated electronically across the Healthcare Division with voting buttons to acknowledge receipt: 2 Our group Medical Director has notified Hospital Medical Directors of this requirement and has asked that discharge of patients is routinely discussed during supervision and appraisal with Independent Doctors.
3. The improvements made in response to your report will be included in the forthcoming Learning Lessons Bulletin which will be circulated in early 2016.
4. The amendments to the policy and the background to those amendments will be raised at the Medical Directors Meeting to be held on Tuesday 26 January 2016. I hope that you will be assured of the actions taken in respect of this matter. Please do not hesitate to contact me if I can be if further assistance Yours sincerely Director of Safety Policy the

IECEIVED J 1 0 DEC 2015 PRIOY 737777255332225 LEOrl Your reference: APWICAH/3821-2014 Tuesday 8 December 2015 Mr Alan P Walsh HM Area Coroner Manchester West HM Coroner' s Court Paderborn House Howell Croft North Bolton BL1 1QY Private and Confidential Mr Walsh Re Suzanne Greenwood Deceased Thank you for your letter dated Monday 12 October 2015; have reflected on this matter and discussed it with my peer group. In light ofyour report to prevent future deaths under paragraph 7, schedule 5 of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013, have worked with Group Management and wider improvements have been made to ensure that lessons are learnt so that similar incidents do not happen again_ Moving forward, will ensure that for all of my patients, after their initial consultation (following first referral or discharge from in-patient) , if they do not attend their next appointment; they will be given a further appointment: A copy of this letter will also be sent to their GP. Should fail to attend a further letter will be sent to the patient ad their GP. If there are concerns about the patient then telephone contact will be made and a follow up letter sent as required: The GP will be given further instructions regarding what to do in terms of medication/further management and advised, if appropriate, to refer the patient to NHS secondary services. The GP will also be given the option to re-refer the patient in future should this be necessary: hope this meets vour approval: Yours sincerely Consultant Psychiatrist The Priory Hospital Altrincham, Rappax Road, Hale; Cheshire; WAIS ONX Tel: 0161 904 0050 Fax: 0161 980 4322 Email: altrncham@prorygroup com WNA priorygrup.com 1 Priory Heatthcare Umied batng as the Piory Hospibal Aluincham: Regtstered Oikxe: Fifth 80 Hammersmith Road, London, W14 BUD: Registered in Engbnd No. 6244860. Part d the Fiory Group df Companies Dear Priory they Aoor;

PIORY GROUP COMPANIES Your reference: APWICAH/3821-2014 RECEIVED Wednesday 9 December 2015 1 Q W2c 2015 Mr Alan P Walsh HM Area Coroner Manchester West HM Coroner's Court Paderborn House Howell Croft North Bolton, BLI 1QY Private and confidential Dear Mr Walsh Re Suzanne Greenwood Deceased Thank you for your letter dated Monday 12 October 2015 in which you enclosed your report to prevent future deaths under paragraph 7, schedule 5 of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. Your report was directed to Consultant Psychiatrist and myself. Iam aware that Director of Safety has provided you with a response on behalf of the company however you have specified that you would like to receive an individual response both and myself: You have asked that a review is carried out of the systems, procedures, policies and protocols in relation to contact with patients who fail to attend appointments. Upon receipt of your report I asked that a review was undertaken of this matter_ Please note that is one of our Consultant Psychiatrists with 'Practising Privileges'. This means that he undertakes his work at Altrincham Hospital as an independent doctor seeing outpatients whilst use of the facilities at the hospital for example the consulting rooms and the IT systems and equipment; Policy H1o5: Practising Privileges for Independent Doctors is clear that independent doctors should work in accordance with General Medical Council requirements and relevant Healthcare Division policies and procedures: This includes participating in regular supervision and appraisal. The policy also states that contract must be signed by the applicable Hospital Medical Director and the particular doctor to that person commencing work as an independent doctor_ As part of our review we identified that the requirement to communicate in an effective and timely way with General Practitioners and others who may be involved with the patient needed to be strengthened in Policy H105. pp Cnrl Lrs A HmauT Priory Group; Fifth Floor; 80 Hammersmith Road, London; W14 8UD Tel: 020 7605 0910 Fax: 020 7605 0911 info@priorygroup.com wwwpriorygroup.com 1 Priory Limited trading as the Priory Group; Registered Offke: Ffth 80 Hammersmith Rood; london; W14 8UD: CHKS 4 Registered England No. 07480152. Part of the Prlory Group of Companies: OF from making Priory prior Group Foor;

You asked that a review is carried out of the systems, procedures, policies and protocols in relation to patients who repeatedly fail to attend appointments and to consider a final letter to the patient indicating that with notifications to General Practitioners or other relevant health professionals of the patients failure to attend appointments and their discharge from hospital the patient will be discharged unless there is either contact or an appointment made within defined period: You also asked that review is carried out of the systems, procedures, policies and protocols in relation to the discharge of patients who repeatedly fail to attend appointments. You asked that the review should consider timescales in relation to discharge when a patient has failed to attend appointments for a specific period of time Please note that we have given our full consideration to these matters and have now made it clear in H105: Practising Privileges for Independent Doctors that independent doctor must complete a final letter to the patient where there has been a repeated failure to attend appointments either with or without notice having been given by the patient: We have specified that the letter must be copied to other professionals involved in the patient's care for example the Generai Practitioner. The letter must give detail of the patient's medication, recommendations for after care and outline the actions to be taken in the event of the patient experiencing a crisis in the future: The letter should also identify possible options for the patient to pursue should they need more routine assistance in the future and these options could include visiting their General Practitioner and/or re-referring themselves to the independent doctor_ In the amended policy we have also identified that the independent doctor should make prompt telephone contact with the General Practitioner in those instances where there are particular concerns about the patient in those instances where the patient has failed to attend appointments. The independent doctor should also as minimum complete and send discharge letter to the General Practitioner and other relevant professionals after the final contact with the patient: The letter must provide detail of the patients medication, the recommendations for aftercare and identify possible actions to be taken by the General Practitioner should the patient experience a future crisis. The letter should be copied to the patient: A number of actions have been taken in relation to giving advice to the independent doctors about the requirements and the adjustments outlined above: 1_ The amended Policy H1o5: Practising Privileges for Independent Doctors has been circulated electronically across the Healthcare Division: 2 The group Medical Director has notified Hospital Medical Directors of this requirement and has asked that the discharge of patients is routinely discussed during supervision and appraisal with Independent Doctors: 3 The improvements made in response to your report will be included in the forthcoming Learning Lessons Bulletin which will be circulated in early 2016.
4. The amendments to the policy ad the background to those amendments will be raised at the Medical Directors Meeting to be held in January 2016. hope that you will be assured of the actions taken in respect of this matter, Please do not hesitate to contact me if I can be if further assistance

Report sections

Circumstances of the death

1. Suzanne Samantha Greenwood died at Haslam Park, Wigan Road, Bolton on the 23rd December 2014 when she was found in a collapsed and unresponsive condition with ligature around her neck and attached to the branch of a tree: She had taken a substantial quantity of Zopiclone and a quantity of alcohol prior to her death: 2_ Greenwood had received treatment from the Mental Health services within the Greater Manchester West Mental Health NHS Foundation Trust in 2002 following a referral from her General Practitioner and in 2005 after she attended the Royal Bolton Hospital Emergency Department:
3. In October 2012 Greenwood self-referred to the Priory Hospital, Altrincham, Rappax Road, Hale: Cheshire as a private patient and she was seen by Consultant Psychiatrist,; on the 5th October 2012. She informed that she had started to use the Mrs Mrs

Zopiclone in 2005 for sleep problems and she had started to purchase Zopiclone online by use of internet in 2007 . Mrs Greenwood was diagnosed as suffering with mental and behavioural disorders due to the use of sedatives and hypnotics (Zopiclone) dependence syndrome and moderate depressive episodes. She was admitted to the Priory Hospital, Altrincham on the 5t October 2012 and she received treatment until she was discharged on 29th October 2012 with a plan for her to attend an aftercare programme at the Hospital.
4. Mrs Greenwood attended review appointments withl_ at the Priory Hospital, Altrincham from the time of her discharge until 21s November 2013, On the 31s October 2013 saw Mrs Greenwood in his outpatient clinic and she reported that her mood had been quite low over the previous 6 weeks and she had been tearful at times; She reported that her had not been good and that she had seen a hypnotherapist to improve her sleep: increased her medication and arranged to see her again on 21s November 2013. On the 21st November 2013 saw Mrs Greenwood at the Priory Hospital, Altrincham and he recorded that Mrs Greenwood had been alot better during the previous week and that there had been a improvement in her mood; completed a mental state examination and recorded that Greenwood's general self-care was good. She was alert her speech was normal, Her mood was euthymic and she had no negative depressive cognitions advised that her medication should continue and he made arrangements to review her in six weeks' time. sent a letter dated 22nd November 2013 to Mrs Greenwood's General Practitioner to confirm the details of the review on 21st November 2013.
5. Mrs Greenwood was given an appointment witht at The Priory Hospital, Altrincham on 9th January 2014 but she cancelled her appointment; which was rearranged for January 2014 but she failed to attend on that date: There was no further contact betweenl and Mrs Greenwood between January 2014 and the 23r December 2014 when Mrs Greenwood died, Igave evidence at the Inquest that he had a Secretary at The Priory Hospital, Altrincham who was emploved by the Hospital; He confirmed that he was a private Consultant Psychiatrist who worked at The Priory Hospital, Altrincham and he was subject to the protocols and policies of the Hospital; He confirmed that; when a patient failed to attend an appointment; his Secretary would usually make contact with the patient to rearrange the appointment; However there was no evidence of any contact with Mrs Greenwood, either by telephone or letter , after she failed to attend the appointment on 16th January 2014 and he had not discharged Mrs Greenwood from his care prior to her death on the 23rd December 2014 the sleep Mrs the confirmed that there had been no contact, either by telephone or letter , with Mrs Greenwood's General Practitioner to confirm that she had failed to attend her appointments in January 2014 and the General Practitioner had not been informed that Mrs Greenwood had not been seen following her last appointment on the 21s November 2013. In fact the letter sent to the General Practitioner byE dated 22nd November 2013 referred to a review on the 21st October 2013, which was clearly an error due to the fact that the review had taken place on the 215t November 2013, (gave evidence that he was not aware, either in his own practice or in the Priory Hospital, Altrincham, that there were any policies or protocols in relation to a system to apply when a patient failed to attend an appointment: Furthermore there was no system in relation to contact with a patient when patient falled to attend an appointment, either to arrange a further appointment or to consider discharge of the patient for repeated failures to attend appointments, and there we no systems in place to contact either General Practitioners or other health professionals who may be continuing to treat a patient; confirmed that there was no timescale with regard to contact with a patient to rearrange a missed or cancelled appointment nor any timescale with regard to the discharge of a patient when a patient had repeatedly failed to attend appointments: 8_ The evidence at the Inquest from the General Practitioner was that there had been further appointments with the General Practitioner after November 2013, including a change in the dose of medication initially prescribed b without the General Practitioner being aware as to whether was continuing to treat Mrs Greenwood: In fact the evidence from an Advanced Nurse Practitioner at the Inquest confirmed that Mrs Greenwood was seen by her in the General Practitioner's surgery on 20th November 2014 when the Advanced Nurse Practitioner reduced Mrs Greenwood"s medication and the Advanced Nurse Practitioner was not aware that her treatment by at the Priory Hospital, Altrincham was still open and that she had not been discharged: The appointment with the Advanced Nurse Practitioner on the 208 November 2014 was almost 12 months after Greenwoods last appointment with) on the 21s November 2013.

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Report details

Reference: 2015-0370
Date of report: 9 October 2015
Coroner: Alan Walsh
Coroner area: Manchester (West)

Responses identified

Responses identified 1 of 1

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 4 Dec 2015 (estimated).

Sent to

Priory Hospital

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