Dear H.M. Coroner Re: Francis James Lea (Your ref: CEM/CAA/OZ131-2016) ~. I am writing to you on behalf of Northfield Medical Centre. The matters of concern raised In your report dated 15th December 2016 have been discussed in a meeting between Hazelmere Medical Centre (HMC), Northfield Medical Centre (NMC) and The East Leicestershire end Rutland Clinical GommiS.sioning Group (GGG). NMC response tv coroner's report: Mr Lea was resident in a care home at a time when a decision had been taken locally to rationalise the GP provision to care homes, as far as possible, to Improve the care ~[ven to patients. The relevant GP practices wrote to the patients, via the care homes, explaining the change and giving patients the option to move GP practices or to remain with their existing practice. A copy of such a let#er $ent by Nor~hfleld ~. '• Medical Centre to its care home pati~.nts is attached. ' Mr Lea was initially ~ p~tier~t dC Nazelmere Medical Centre but the GP practise allocated to his care home was Northfield Medical Centre. Where patients were happy to move GP practice, this was facilitated by the care home, as was the case for Mr Lea. Mr Lea agreed to change GP practice and there was no suggestion that he did not have the capacity to make the dEcisibn to change GP. In such circumstances, the GP practice Is not in a position to inform tEte next of kin due to the duty of confideneiaifty~ owed to the patient and practical difficulties of identifying relevant members of the fami{y or next of kin.

No. 3583 P. 3 8, Feb. 2017 13.28 ~' As a Consequence, is appears that although the care home and Mr Lea were aware ~; that Mr Lea had changed GP practice, Mr Lea's family were not. In order to avoid such a situation arising again, we will as a practice be liaising with the care homes to request that:
• Where a patiQnt, with capacity, who is resident in a care hgme, changes GP `' . practice and this chan~e,is facilitated by the care home, arrangements are put in place for the care home to provide written confirmation that the patient is aware of the change, the patient gives consent to the change ar~d tha# where appropriate the patient's next of kin have been informed. .:
• Where a patient lacks capacity, the care home should provide written con~rrmation that the patient's next of kin has been properly informed and consents to tf~e change of GP practice. Ifi there are any concerns about capacity it would be expected that the care home would raise #here.
• Wherever a Registration Form i~ signed an a patient's behalf, the person ~ .. signing the form on the patient's behalf will be required to print their name and their relationship to the patient. In addition it has been agreed that any future projects such as that undertaken to ,: .. rationalise GP provision to care homes, as referred to above, should include better advertisement, including in the farm of posters, so that families, next of kin and staff ace fully curare of proposed changes. ; ~ ' For an existing IoCal agreement above changing patient care from one Ioca( practice to another when a patient resides in a tare home, any communication arriving at the old practice in the 6 week period between deduction from the old practice and . . registration at the new practice wil! be forwarded onto the new practice, in addition tv a copy being returned to the sender. , . With regard to a safe end effectEve transfer of care, it has been agreed that to avoid any similar accidents, for any future ~ocaliiy projects there will be a written policy ~ ~ which needs to have been signed off by all parties as do the clear process of facilitating any change of GP regi~tratiQn and who will be informing the next of kin ~~ where appropriate. Yau Ithfull 4n behalf of the Northfield Medical Centre

Dear Mrs Brown Re: Francis James LEA Thank you for sending us a copy of your report and recommendations following the inquest into the death of Mr Francis James Lea which took place in December 2016. I thank you for bringing these to my attention, this type of learning is very important to East Leicestershire Rutland Clinical Commissioning Group (ELR CCG), helping us to make important improvements to the way in which services and care is provided for people living in our area. As part of our investigation into the matters raised in your recommendations, the ELR CCG Head of Nursing and Head'of Patient Safety were asked to look into your concerns and provide a response. This has then been reviewed by the Chief Nurse and Quality Officer at ELR CCG to ensure that all of your concerns have been answered and adequate action has been taken as a result. The investigation team have carried out a thorough investigation in order to respond to each of your concerns below. For ease of reference; we have included your original request in italics. For a patient in a care situation, with declining cognitive function (as set out in his home care plan) it would seem appropriate to consider involving the next of kin in any significant decision such as a change of GP. This would have enabled the family (who always ensured they accompanied Mr Lea for any medical care) to pass on the updated information and this outcome would have been avoided. Managing Director: Mrs Karen English Chair: Dr Richard Palin

During the course of our. investigation, we have been informed by the care home manager that Mr Lea did have the capacity to make the decision to change GP practice. If a person has capacity, there is no requirement to inform the next of kin. However, we recognise that engaging with residents and their families is best practice when making changes such as this. Therefore there are a number of actions that will be put in place to ensure families are aware of future changes with which the CCG is involved:
- When making changes, there must be a robust project plan, including plans for communicating and engaging with all stakeholders.
- Ensure communication and engagement plans include engagement with the family and next of kin. So that whether residents have capacity to make decisions or not, their families will be aware of potential changes.
- Project plans will clearly identify the responsibilities of all parties for sharing information.
- All communications regarding planned changes will be shared with all members of staff at care homes and GP practices. There appeared to be no notes on the patienf's medical record regarding the rationale for this change, or any consent from the patient that he was in agreement that it should take place. There was also no record of whether any consideration of his capacity has been undertaken, and if so what the outcome of that decision was. Residents/patients are assumed to have capacity unless proved otherwise. As part of this project residents were given the choice as to whether to move practice. In future projects of this type, ELR CCG makes the following recommendations:
- Any proposed changes are discussed with the patient and documented by the organisation instigating the change.
- In future projects, ELR CCG will require providers to kEep a record of information received and discussed with residents. There will also be a requirement to include potential changes in care plans, and on the relevant clinical systems.
- Project plans will include communications to care homes reminding them to update patient records in a timely manner. During the course of the investigation it was established that the care home manager had signed the form on behalf of Mr Lea although this was not made clear to the Practice. Therefore we will be contacting all care homes to recommend:
- Policies and processes are put in place when staff are required to sign on behalf of residents who have capacity who are physically unable to sign a document (including documentation standards i.e. designation, black ink, print, two to sign and date). Since the time of this incident, we have issued standard practice application forms to all of our membership practices. This includes a section for signing on behalf of somebody else.

Given this was a joint decision between the GP surgeries and the care home, it would seem that each surgery should share responsibility for a safe and effective transfer of care and therefore this report is being sent to each surgery for further consideration and the CCG. It is clear that there could have been better communication between the different parties involved in the project. In future we will recommend that: All project plans must clearly outline roles and responsibilities for each of the parties involved
- All communications involved in a project must be clearly dated and documented (including templates for letters etc.)
- When making changes to practice lists, not initiated by the patient, there must be a system for forwarding on communications regarding these patients for an agreed timescale (i.e. minimum six weeks).
- Carehomes should have systems for tracking information shared with GP practices; information should be documented in care plans and signature sheets may be required to track information depending on the circumstances.
- In future projects, ELR CCG will require providers to keep a record of information received and discussed with residents. There will also be a requirement to include potential changes in care plans, and on the relevant clinical systems. In addition to the actions already identified, a serious incident investigation has been opened into this case to ensure the widest possible learning. This is amulti-agency investigation, including the two GP practices, the care home, University Hospitals Leicester NHS Trust (UHL) and ELR CCG. We also intend to share the issues raised in your letter with our contracts teams who monitor the CCG's contracts with care homes and GP practices. This enables our contracting team to seek assurance from provider organisations, in respect of how they implement lessons learnt from an incident with an aim to improving patient care. hope the enclosed response provides assurance about the actions taken following your recommendations.

Dear H.M. Coroner Re: Francis James Lea (Your ref: CEM/GA/02131-2016) am writing to you on behalf of Hazelmere Medical Centre I am sorry to hear about the events surrounding the care of Francis James Lea. The matters of concern raised in your report have been discussed in a meeting between Hazelmere Medical Centre, Northfield Medical Centre and The Clinical Commissioning Group (CCG). The medical records of the patient do not reflect any evidence of declining cognitive function requiring the need for a formal capacity assessment. The communication with the care homes in this project of swapping care home patients between practices was explicit in stating that the change of registered GP was an active informed decision to be communicated to the patient, or if the care home felt there was a lack of capacity for this to be discussed with next of kin. As part of this project letters were written to the care home patients which was sent to Mr Lea as well detailing the above. Hence it was assumed that M r Lea had capacity to engage in this process. As part of the learning point from our joint discussions it has been proposed in the future to avoid any similar incidents there is need for better advertisement of any such wide changes, in the form of posters. A,specific recommendation is the need for written signed documentation of the conversation with the patient or next of kin as appropriate. There is usually no need for documenting on patients medical records regarding rationale for change of GP. As highlighted the care home was facilitating change of GP and patients were offered the choice of declining to change their registered GP. As mentioned earlier it is not common practice to hold capacity assessment unless there is a medical need.

y ~` `° -~~' ~`~`''~~~ HAZELMERE MEDICAL CENTRE Y`` ,~~~
- ~ " ~~ 58 Lutterworth Road, Blaby, Leicester LE8 4DN =~
- Tele hone: 0116 2771666, Fax: 0116 2772416 p Website: http:www.hazelmeremc.co.uk As a result of the meeting between the practices and the CCG it has been agreed that to avoid any future similar incidents any communication received by the donor practice, in addition to the usual practice of the communication being sent back to the sender; will in addition be forwarded to the receiving practice for up to a period of six weeks from the change of registered GP.