8 OECEIVED From Ben Gummer MP 0 3 NOV 2015 Parliamentary Under Secretary of State for Care Quality Departmert-33235323 Richmond House of Health 79 Whitehall London POCS 960976 SWIA 2NS Tel: 020 7210 4850 Mr A. Walsh Area Coroner Bolton Coroner' s Office Paderborn House Howell Croft North 3 0 Oct 2015 Bolton BLI IJW klz ( Ull Thank you for your letter of 28th September 2015,following the inquest into the death of Pryal. I was sorry to hear of Mr Pryal's death and wish to extend my condolences to his family. There appear to be two main issues of concern that you raise in this case. One is that X-ray information was not available in a timely manner to all of the professionals caring for Mr Pryal: You outline the circumstances which led to this situation and direct several concerns to the 5 Boroughs Partnership NHS Foundation Trust (SBP) and Wrightington Wigan and Leigh NHS Foundation Trust (WWL) which relate to their joint Service Agreement, the reporting times for X-rays, the electronic systems available to support web viewing of X-rays and the recording of appropriate patient notes. These concerns are about the local systems that are in place and rightly addressed to the local providers, who I am confident will consider and review. The other main issue You raise is about the lack of recording of information in the patient 's notes, by medical professionals, that would have ensured a consistency of care for the patient Not only was this an issue in this case but evidence suggested that the lack of recording of appropriate notes in hospital patient records is & problem on a nationwide scale. Whilst the actual recording of patient notes is something that is agreed and implemented at local level, the general move away from paper to integrated digital care records should improve the comprehensiveness of information held, including essential diagnostic tests and it's availability to all professionals engaged in the care of individual patients. Harry

further advantage of digital systems is that they can be programmed to alert all professionals involved in the organisation and delivery of care about any outstanding test results_ Currently, the Health and Social Care Information Centre (HSCIC) is developing the Transfer of Care Initiative. Further information about the Initiative can be found on the HSCIC website. This Initiative recognises that; in order to support the delivery of high quality care; there is an increasing need to share information in a more efficient and consistent way across health and social care_ This is especially important in care settings that cross organisational boundaries The Initiative aims to enable consistent electronic exchange of information between different care professionals and organisations This will be achieved by driving the establishment and uptake of consistent professional and technical Transfer of Care data standards across the health and care sector; in direct support of the National Information Board (NIB) objectives, to 'help clinicians ensure that patients are safely transferred between episodes of care In terms ofhow information is captured and recorded in a consistent manner in clinical systems; the Academy of Medical Royal Colleges (AoMRC) has produced Standards for the clinical structure and content of patient records (2013). These Standards can be found on the Royal College of Physicians website. This work is important in standardising approaches for clinicians and healthcare professionals regardless of the care setting and is equally relevant for those who develop and implement electronic or paper care records. The AoMRC standards document states: 'To record clinical information in @ way that can be shared and re-used safely in an electronic environment; the structure must be standardised For this to be realistically achievable, the standards for structure must reflect the way that patients and clinicians work together to the common of best practice and high quality care. This necessity has been recognised by the establishment of an independent Professional Record Standards Body to oversee rigorous development and maintenance Of health and social care records _ The scope of the AoMRC standards includes the structure and content of patient records, covering hospital referral letters, inpatient clerking, handover communications, discharge summaries and outpatient letters. The adoption of these standards was proposed by the National Information Board in their published framework for action, (November 2014) which states: goal _

"We propose the adoption of the Academy of Royal Medical Colleges' publication Standards for the clinical structure and content of patient records, with a requirement that all organisations and clinical systems should implement the standards, following consultation and completion of an impact assessment. In addition, the HSCIC strategy 2015-20, Information and technology for better care, drew particular attention to the AoMRC standards: We will lead the work to deliver one of the commitments in the National Information Board Framework for all health and care organisations to adopt the Academy of Royal Medical publication Standards for the Clinical Structure and Content of Patient Records: This will improve the timely integration of information across care settings The AoMRC standards are being further developed and implemented as part of the Transfer of Care Initiative. The Initiative has already published specifications AoMRC standards for the electronic transmission of discharge summaries between acute and mental health providers and GPs. [am grateful to for bringing the circumstances of Mr Pryal 's death to my attention and hope that you find this reply helpful. CO1T 8hele BEN GUMMER key Colleges using you

Dear Mr Walsh Regulation 28 Report Many thanks for the Regulation 28 Report dated 28th September 2015. This letter is to provide you with assurance that actions are being taken by the CCG in response to the report and the actions that you have recommended to prevent future deaths_ Action VI was "A review of the provision of physiotherapy and occupational therapy to deal with the physical health needs of patients at the Lakeside Unit, to ensure that appropriate treatment is available to those patients"_ In response to the above recommended action, the CCG has formally written to SBP on 13t October 2015, stating that the CCG believes that SBP should have a service agreement in place with a suitable provider for the provision of physiotherapy and occupational therapy: Please see letter attached (Appendix A): 5BP has since confirmed via e-mail dated 28th October that assurance that all requests for physiotherapy or occupational therapy will be flagged to SBP Clinical Director who will ensure that this need is met. Please see e-mail attached (Appendix B): The CCG does not envisage this to be an issue going forward, however, if there are, then it will be dealt with at the Contract Monitoring Group Meetings with 5BP . Wigan Life Centre College Avenue WNI INJ www wiganboroughccg nhs.uk Chairman: Dr Tim Dalton Chief Officer; Trish Anderson Healthy People, Healthy Place. Wigan

WHS Wigan Borough Clinical Commissioning Group

Dear Mr Walsh Regulation 28 Response: Pryal (Deceased) Thank you for your Regulation 28 Report to Prevent Future Deaths, dated 28 September 2015. Within that Report a number of concerns were highlighted to Wrightington, Wigan and Leigh NHS Foundation Trust ("the Trust") following the evidence heard at the inquest of Mr Harry Pryal held on 3 and 4 September 2015 have been fully advised of the circumstances relating to Mr Pryal's death, and having read your Report, am gratefulto you for bringing these concerns to my attention: Since the conclusion of the inquest the Trust has undertaken a great deal of work to address these areas of concern, and have been working alongside the 5 Boroughs Partnership NHS Foundation Trust ("SBP"), to ensure lessons have been learnt from the events surrounding Mr Pryal's death_ would like to take this opportunity to advise you ofthe actions already taken by the Trust to address the concerns outlined on pages and & of your Report; and proposed action to be taken in the future: The provision of notes within hospital records in relation to any telephone referrals or other referrals from health professionals for advice in relation to the treatment and care ofa patient, The review Chairman: Robert Armstrong Chief Executive: Andrew Foster CBE DIsAB Wigan Harry any Jouti 6

should include the retention of such notes for observation by other clinicians who may become involved subsequently to ensure continuity of advice in relation to treatment and care: understand the above was also raised with SBP, as well as the Secretary of State for Health, as it was acknowledged that this was a nationwide concern: It has been shared with the Trust's Clinical Directors for Medicine, Scheduled and Unscheduled Care; to enquire into what processes could be in place within the organisation _ am advised that the Trust's Medical Registrar on-call receives approximately 60 to 70 bleeps a during his 12 hour shift: The majority of those relate to internal queries; however around 5-10% are telephone referrals from external providers, (such as SBP, GPs, and other NHS hospitals) Often these calls are taken whilst the health professional is on a ward undertaking clinical duties, therefore making it difficult for a note to be made of that discussion, especially as these calls do not relate to patients currently being treated within the Trust_ The majority of these external referrals also relate to patients who do not have medical records, either because they have never attended the Trust before; or the medical records are held offsite in storage (making them inaccessible at the time of the discussion): This makes it very difficult for the health professional to document a contemporaneous record of the referral According to the General Medical Council, and Royal College guidance, there is a duty on the health professional seeking the advice to ensure a full and accurate record is kept; note a directive has been given to clinicians within SBP to ensure all clinical advice received is fully recorded, and for the documentation to include the health professional'$ name, grade and contact details_ In addition, the Trust has been working with SBP to create a standardised proforma for use on transfers between the two organisations (please see Appendix 1) The proforma, setting out the patient's medical background, reason for referral, and any prior discussions, would be sent upon transfer and kept within the medical records. Both Trusts are looking to pilot these proformas following approval from the respective clinical committees As stated above, note this matter has been raised with the Secretary of State for Health: would be grateful if vou could share his response to this concern so that we seek to take further action, in addition to that outlined above put day may

A review of the Iiaison, understanding and interpretation of the provisions of the Service Agreement in relation to Radiology for the period from the 1 April 2015 to 31 March 2016 and subsequent years, taking account of the evidence heard at the inquest: The review should include the operation and performance of the terms of the Agreement; and should extend to the involvement of the two Trusts, particularly on the same site at Leigh Infirmary: The review should also take account ofany other Service Agreements in existence and entered into by both Trusts either collectively or individually: Shortly following the conclusion of Mr Pryal' $ inquest; discussions were held regarding the interpretation ofthe Service Agreement for Radiology between the two organisations. Leading on these discussions for the Trust has been ((Associate Director of Finance) and Andrew Beatty (Radiology Directorate Manager) , with (Contract Manager for SBP): A further meeting was held on 18 November 2015 where a joint review was undertaken of the Service Agreement for Radiology to ensure patient safety is now at the heart of specification and Andrew have also presented to the Trust's Quality and Safety Committee on what lessons have been learnt following Mr Pryal's death. It is acknowledged that there are a number of other Service Agreements the Trust has in place with SBP, which relate to pharmacy, anaesthetics, domestics, psychology, counter fraud and estates: These Agreements have also been discussed and work is undertaken to review the terms to ensure a consistent approach by both organisations_ In addition to the above, the Trust's Standing Financial Instructions (SFI's) have also been updated in respect of the process for sign off for Service Agreements (please see Appendix 2). The attached document will be used as a sign off sheet; and is now required for every new Service Agreement the Trust enters into. The revised SFIs have been approvedat Trust Board level The Service Agreement will be owned by the operational manager ("Responsible Officer" within the department which it relates to. It will be their responsibility to send out the sign off sheet to all those named seeking approval, and thereafter to cascade it down to those who provide the service (i.e. the health professionals) to ensure it is complied with. Divisional Accountant will remain responsible for the financial aspects of the Service Agreement; and the document itself will sit with the Trust Board Secretary: any the being The

A review of the electronic systems, which allow access by SBP to network connections in relation to WWL systems, particularly to allow web viewing of x-ray examinations in accordance with the Service Agreement Following discussions with SBP, it was agreed that the Trust would grant secure web based viewing for all diagnostic reports via a secure system which can be accessed by an agreed username and password It will be decided by SBP which oftheir health professionals has access to this system_ This is an interim measure until further developments can be made via the Trust's HIS system which is due to be implemented next year. The Trust is aware that not all health professionals at SBP have the expertise to identify interpret diagnostic reports. Therefore in addition to the above, the Trust has a 24/7 "on call" Radiologist who is able to assist in interpreting X-rays, scans etc, ifthe health professionals are unable to do so. This has been communicated to SBP who in turn will share this information with their staff: A review of the reporting times for X-ray examinations with particular reference to triage to identify any urgent or unexpected significant clinical findings, which will need to be communicated to the referring clinicians at the earliest time. In the case of Mr Pryal, the X-rays undertaken by SBP at Leigh Infirmary were treated the same as if he were based at an out-patient facility: It is acknowledged that there was a lack of understanding by health professionals at the Trust that Lakeside Unit is an inpatient facility- Mr Pryal's X-rays should have been reviewed as if he was an inpatient; and then they would have been reported sooner: Discussions been held at the Radiology Governance Meeting on 22 September and 15 October 2015 reminding all health professionals that patients at Lakeside Unit are to be treated as in-patients. The Radiology Information System (CRIS) has also been updated to reflect this, to prevent a similar delay occurring Within the Emergency floor at the Trust there is a "red dot" system in place so that if Radiographers have any concerns, an * is put on the CRIS system to alert the referring clinician that they may be an untoward finding: This is something that is currently being considered to be used throughout the organisation, ongoing discussions at being held within the Governance meetings_ and have and

"Hot reporting" has also been in place since early 2015 during week days. This means that X-rays are reported "as close to immediately as possible following the X-ray being undertaken" (unless the referring clinician is able to review and interpret them directly). This is currently not in place at weekends due to lack of resources However reporting radiographers are currently trained to interpret chest X-rays One has already been trained and funding is in place for another: Due to Mr Pryal's X-ray request including a chest X-ray it meant; at the time, that it had to be reported by a radiologist: Due to New Year and bank holidays, there was no radiologist available to report plain films, which led to the delay: The risk ofthis delay happening again has been reduced by the introduction of Specialist Radiographer chest X-ray reporting: Finally consideration is also given to creating a Policy or Standard Operating Procedure around radiographers identifying unsuspected clinical findings, and bringing urgent X-rays to radiologist's attention: This is also being discussed at the Governance meeting within the Radiology department: hope the above response is testament to how serious the Trust has dealt with the events surrounding Mr Pryal's death: Ifyou have any comments or suggestions in relation to the proposed actions above, would be only too pleased to hear from you_

Dear Mr Walsh Re: Harry Pryal Thank you for your letter dated 28 September 2015 with regards the inquest findings into the death of Mr Pryal and the directions given under regulation 28 of the Coroners and Justice act 2009 (a2013). would like to inform you that many actions were being progressed by a number of the organisations to the inquest and this has enabled the Trust to provide you with a detailed response In preparing this response 5 Boroughs Partnership NHS Foundation Trust (the Trust) have worked jointly with Wrightington; Wigan and Leigh NHS Foundation Trust and have been in contact with Wigan Clinical Commissioning Group to ensure that all actions align to achieve a more integrated care pathway_ would like to advise you of the actions the Trust has taken since receiving your letter. Taking your points in turn can confirm the Trust has taken the following steps: The provision of notes within hospital records in relation to telephone referrals or other referrals for advice in relation t0 the treatment care Of the patient: Chief Executive: Mr. Simon J Barber Chairman: Mr. Bernard Pilkington Trust Headquarters , Hollins Park House, Hollins Lane; Winwick, Warringlon, WA?Z 8WA Mini Com Number 01925 664094 "1s48 Your prior and

We have developed a standardised proforma for use_on transfer between the Trust and Wrightington, Wigan and Leigh NHS Foundation Trust to be kept within the care record: These proforma have been created by the clinicians who will be using them and have been discussed at the Wigan Medial Staff Committee (minutes available) We have shared this work with our colleagues in Wrightington, Wigan and Leigh NHS Foundation Trust who are looking at a pilot to test the clinical appropriateness of the proforma. A directive has been given to all clinicians within the Trust relating to the recording of clinical advice by specialist services. In Mr Pryal's case; this was with the medical registrar for medicine. There is requirement that all clinical advice we receive is fully recorded, with emphasis on the recording of the name; grade and contact details of clinical colleagues we speak to. This been sent out for immediate action via an internal email: Although this incident occurred in Wigan, it is important to share the wider learning across the Trust To facilitate the learning this incident will be discussed at the next Lessons Learned Forum on 24 November 2015 chaired by our Medical Directors_ Further dissemination of the lessons learned from this incident will be developed at the forum and will be communicated Trust wide_
ii. A review of the Iiaison, understanding and interpretation of the service level agreement in relation to radiology: A joint review of all SLAs held between Wrightington, Wigan and Leigh NHS Foundation Trust and 5 Boroughs Partnership NHS Foundation Trust is underway: This includes, and has started with the service level agreement for the provision of radiology services The review process will incorporate the following steps: a) A thorough review of service specification by 5 Boroughs Partnership NHS Foundation Trust clinicians to assure themselves that the service specification is sufficiently robust and specific to support the provision of clinically safe services_ b) A review of the service specification by Wrightington, Wigan and Leigh NHS Foundation Trust to ensure that the agreed service specification is deliverable. c) A review of the wording in the service level agreement to remove any ambiguity and to ensure a consistent interpretation by both parties_ d) The identification of performance indicators management information to be provided to allow for appropriate monitoring of the service provided. e) Identification of a 5 Boroughs Partnership NHS Foundation Trust clinical and operational lead for each service level agreement: Scheduling of routine service review meetings between 5 Boroughs Partnership NHS Foundation Trust and Wrightington, Wigan and Leigh NHS Foundation Trust_ Chief Executive: Mr: Simon J. Barber Chairman: Mr: Bernard Pilkington Trust Headquarters , Hollins Park House Hollins Lane, Winwick Warrington, WAZ 8WA Switchboard 01925 664000 Better View_. of mind & body has the key

Feedback from 5 Boroughs Partnership NHS Foundation Trust clinicians on service specifications is being sought and an initial meeting with Wrightington , Wigan and Leigh NHS Foundation Trust has taken place.
iii. Review of electronic systems At present each organisation is responsible for the creation, safe storage and maintenance of its own clinical records. As we move to an ever increasing paper-light NHS, we are now doing more and more on computers_ In Mr Pryal's case_ there was a failure between the Trust and Wrightington , Wigan and Leigh NHS Foundation Trust to appropriately locate or share information critical to Mr Pryal's care: As an immediate but interim step, we have received agreement from Wrightington, Wigan and Leigh NHS Foundation Trust to secure web- based viewing to all diagnostic reports via system that can only be accessed from an NHS computer via a secure log in. The provision of the log-in accounts is in progress but early signs are that all substantive medical staff will receive one, and we are reviewing how we manage out of hour's access with the medical rotation of doctors. This challenge will form part of our on going action plan_ Wigan Borough Clinical Commissioning Group has set out commissioning intentions for the 2016/17 contract with the focus on delivery of the borough's major transformation programme_ In November 2015 the urgent care service who deliver out of hours care and assessment were granted access to the Medical Interoperability Gateway This allows real time access to all primary care records that the service has permission to see_ Whilst this doesn't directly Iink to Mr Pryal's case_ this is a further step taken to align health information in the Wigan Borough: All clinical letters and information routinely sent to a GP_ in this case information from Wrightington, Wigan and Leigh NHS Foundation Trust to GPs will be accessible with patient consent to Trust staff. As the Trust is moving to a purpose built bespoke mental health hospital in 2016/17 an IT work stream has been initiated to review all future IT connectivity needs to ensure that all these systems are fully compatible in the new hospital once we move off Wrightington, Wigan and Leigh NHS Foundation Trusts site_ This project has recently incorporated North West Ambulance Service.
iv. Review of notes The Trust's records manager is reviewing the process for clinical record audit in line with recent organisational changes that have occurred_ This is completed by the Records Management team and reported to the Chief Nurse and Executive Chief Executive: Mr. Simon J. Barber Chairman: Mr. Bernard Pilkington Trust Headquarters , Hollins Park House Hollins Lane Winwick Warrington. WAZ 8WA Switchboard : 01925 664000 Better View_. of mind & body have being

Director for Operations This process will audit policy compliance over paper and electronic records and following the review, recommendations for change are to be considered in the amended final policy. v: Review of the provision of physiotherapy and Occupational Therapy: The Trust has carried out a review to identify need in this area and to identify the clinical pathway and demand Discussions at a senior level are taking place between 5 Boroughs Partnership NHS Foundation Trust and Bridgewater NHS Foundation Trust to clarify arrangements for the provision of physiotherapy and occupational therapy: For the interim period, requests for physiotherapy and occupational therapy from the in-patient wards at Leigh Infirmary are being flagged urgently to our Professional Lead for Allied Health Professionals who will source the appropriate professional from our wider Trust resource She will also complete the required specification for submission to Wigan Clinical Commissioning Group to maintain the service either from Bridgewater NHS Foundation Trust or the Trust will identify an alternative supplier.