David Baddeley
PFD Report
All Responded
Ref: 2015-0451
All 1 response received
· Deadline: 16 Dec 2015
Sent To
Response Status
Responses
1 of 1
56-Day Deadline
16 Dec 2015
All responses received
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Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Coronersconcerns
The concerns noted by the Court the course of the Inquest are as follows:
1) That_the transfer of patients_electronic_records between medical taking day, from May May May they they Court May they they during practices can mean that information iS not highlighted due to the incompatability of the systems.
2) The practice which patient is is not notified of the new practice taking over the patients care S0 that doctors can speak and discuss any pertinent medical issues.
3) The length of time it takes for & medical practice to receive the full paper medical records. Due to the volume of work the fact that it takes 8 weeks for & patients paper medical records to be reviewed and summarised.
5) The fact that the initial new patients health did not note that Mr Baddeley had serious psychiatric illness, which could have made him a risk to himself or indeed others as he was not his antipsychotic medication. That when his paper records were reviewed on the 1sth pertinent Was thought required and again his mental health diagnosis and lack of medication not picked up.
1) That_the transfer of patients_electronic_records between medical taking day, from May May May they they Court May they they during practices can mean that information iS not highlighted due to the incompatability of the systems.
2) The practice which patient is is not notified of the new practice taking over the patients care S0 that doctors can speak and discuss any pertinent medical issues.
3) The length of time it takes for & medical practice to receive the full paper medical records. Due to the volume of work the fact that it takes 8 weeks for & patients paper medical records to be reviewed and summarised.
5) The fact that the initial new patients health did not note that Mr Baddeley had serious psychiatric illness, which could have made him a risk to himself or indeed others as he was not his antipsychotic medication. That when his paper records were reviewed on the 1sth pertinent Was thought required and again his mental health diagnosis and lack of medication not picked up.
Responses
Response received
View full response
Dear Miss Kearsley Regulation 28 Report Mr David Anthony Baddeley Thank you for your Regulation 28 Report regarding the death of Mr David Baddeley and the concerns with regard to avoidable harms. NHS England, GPs and Clinical Commissioning Groups have also identified the risks to patients where records do not make obvious the tests, allergies or other significant clinical matters. diagnoses, blood 2 Since the advent of the new GMS contract, circa 2004, Care have been incentivised and contracted to apply accurate electronic practices coded items (READ codes are fixed and specificacodesteseectooreicORE Aati diagnoses, blood test results, allergies and so on within clinical patient GP contract terms require IT systems to be approved and demoratraretem): compliance to these IT standards_
3. Where records are transferred electronically, the READ codes are to be used by the recipient practice to establish for themselves, in conjunction with medical records summary the clinical needs and conceros relating totthany patient: The sending practice has a data governance obligation in ensuring accuracy. Today_the electronic transfer of patient records within England takes place using GPZGP . This is the consistent single tool for practices to transfer all READ coded items automatically to the receiving clinical system . All narrative data is also transferred. This occurs regardless of the computer system used, providing that both %f the practices are GPZGP enabled (currently 98% of Gp practices in England have GPZGP capability): can confirm that the two practices involved are GPZGP enabled. High quality care for all, now and for future generations Anthony key = Primary the
OFFICIAL-SENSITIVE: PERSONAL 14_ SHS England has recently procured Capita to manage it' s Primary Care Support Services. One of the work streams is the management of medical records From June 2016 it is planned that practices will be able to track records and see expected delivery dates. In the meantime, practices necessary; request paper records urgently: can, when
15. Electronic records can be summarised in the usual way at the receiving practice If there is a concern about a patient; the practice GP summarising of a particular set of notes, usually at the may prioritise the request of the clinician who may be after them at new practice, especially if it is felt that the patient may have complex medical
16. Note summarising was included as part of the national GP contract as part of the and Outcome Framework: This ceased at the end of 2012/13 when it was retired on the grounds that it was standard good practice maintained. This standard for this indicator was that 80% of and would be patients had their notes summarised within 8 weeks Of newly registered receipt by the practice.
17. Practices will be reminded to ensure that when patients are seen at health checks that are screened for serious new patient psychiatric illness 18 Practices will be reminded to ensure that when a patient transters 0 another praciceo €asure hatiereecopatteoth Jeieciorec and should be checked to ensure that significant diagnoses and paper; are recorded, highlighted and correctly coded. My apologies for the small delay in sending this response This response is on behalf of NHS England Lancashire and Greater Manchester: shared letter with the North of England Medical Director to learn if this this behalf of NHS England more widely: am awaiting response can be on a response
3. Where records are transferred electronically, the READ codes are to be used by the recipient practice to establish for themselves, in conjunction with medical records summary the clinical needs and conceros relating totthany patient: The sending practice has a data governance obligation in ensuring accuracy. Today_the electronic transfer of patient records within England takes place using GPZGP . This is the consistent single tool for practices to transfer all READ coded items automatically to the receiving clinical system . All narrative data is also transferred. This occurs regardless of the computer system used, providing that both %f the practices are GPZGP enabled (currently 98% of Gp practices in England have GPZGP capability): can confirm that the two practices involved are GPZGP enabled. High quality care for all, now and for future generations Anthony key = Primary the
OFFICIAL-SENSITIVE: PERSONAL 14_ SHS England has recently procured Capita to manage it' s Primary Care Support Services. One of the work streams is the management of medical records From June 2016 it is planned that practices will be able to track records and see expected delivery dates. In the meantime, practices necessary; request paper records urgently: can, when
15. Electronic records can be summarised in the usual way at the receiving practice If there is a concern about a patient; the practice GP summarising of a particular set of notes, usually at the may prioritise the request of the clinician who may be after them at new practice, especially if it is felt that the patient may have complex medical
16. Note summarising was included as part of the national GP contract as part of the and Outcome Framework: This ceased at the end of 2012/13 when it was retired on the grounds that it was standard good practice maintained. This standard for this indicator was that 80% of and would be patients had their notes summarised within 8 weeks Of newly registered receipt by the practice.
17. Practices will be reminded to ensure that when patients are seen at health checks that are screened for serious new patient psychiatric illness 18 Practices will be reminded to ensure that when a patient transters 0 another praciceo €asure hatiereecopatteoth Jeieciorec and should be checked to ensure that significant diagnoses and paper; are recorded, highlighted and correctly coded. My apologies for the small delay in sending this response This response is on behalf of NHS England Lancashire and Greater Manchester: shared letter with the North of England Medical Director to learn if this this behalf of NHS England more widely: am awaiting response can be on a response
Action Should Be Taken
It should be noted that both of theenediczou practices involved in this particular case had themselves noted flaws in the systems and taken steps to address some of the issues themselves; howevee the of the Court highlight an issue which may impact on medical practices across Manchester.
Report Sections
Circumstances of the Death
As indicated Mr Baddeley: an extremely intelligent gentleman; had standing diagnosis of Schizophrenia which was controlled with very medication. He had had a number of hospital admissions anti-psychotic the majority of his life Mr Baddeley had lived ithroeghoan his life . For Tameside area Approximately 4 years ago he moved to the Stockport area. He had a GP in Cheadle Whilst in Stockport he had a number of admissions to Hospital. His last admission in 2013. TberrofnadSepteonbet2Stepbie €ouni heard evidence that the deceased moved back to the the Court Tameside Area. He registered with the Ann Street Medical Practice in Denton and first attended surgery in September 2014 for an unrelated condition. At this the records were not with the practice rchege didhaotoriv hiil &geaSis manual after he had registered. a month Due to thewolume ofpatients and medical records the Court heard that it ~ until the 9th March 2015 that a summary of his medical records was not was completed Coroners history being from long being Jeast
Even then it was not clear that this was patient with an underlying health condition. mental On the 30" March 2015 Mr Baddeley made an appointment with the requested a repeat of his Amisulpride medication which he practice and twice advised he was although he did indicate he had reduced his dose due to side effectse At this stage his GP advised he would contact his previous further information as it was not possible hie {toioutiorsychaataisle f determine when he had last been seen: He also prescribed available to medication for & period of 4 weeks. his Amisulpride The Court heard that the information from the psychiatric services received until the 6th 2015. was not However on the 1st Mr Baddeley had attended the practice practice nurse that he had moved and would be registering and advised the closer to where he now lived. with a new practice On the 12th he registered with the Davaar Medical Centre in Dukinfield his records from Ann Street had been forwarded electronically. and The Court heard that whilst the medical records are sent electronically GPs not aware of which practice are sent to. The Court heard are known the details of the practice Mr Baddeley had that if the GP had registered with he would have spoken to them about his mental health issues and the fact that he longer to be under psychiatric services and was not receiving his appeared no medication (Save for the one prescription issued OnOhee3o"Mgrch} anti-psychotic The Court also then heard from GP from the Davaar Medical Practice. advised the Court that due to the fact that medical practices He are on different computer systems; when Mr Baddelys' electronic records were received the fact that he was diagnosed with Schizophrenia was not obvious in the formatc were received. On the 18th May Mr Baddeley attended for & new patient check and Healthcare assistant; but this was limited and the was seen by Healthcare Assistant would not have been expected do have Coad alehrdeleatote records which had been received the electronic The Davaar Medical practice did not receive Mr Baddeleys written the 28th 2015,these were not reviewed until the asieyuneritleheecheds wetd reviewed were detailed as not requiring any action. were
Even then it was not clear that this was patient with an underlying health condition. mental On the 30" March 2015 Mr Baddeley made an appointment with the requested a repeat of his Amisulpride medication which he practice and twice advised he was although he did indicate he had reduced his dose due to side effectse At this stage his GP advised he would contact his previous further information as it was not possible hie {toioutiorsychaataisle f determine when he had last been seen: He also prescribed available to medication for & period of 4 weeks. his Amisulpride The Court heard that the information from the psychiatric services received until the 6th 2015. was not However on the 1st Mr Baddeley had attended the practice practice nurse that he had moved and would be registering and advised the closer to where he now lived. with a new practice On the 12th he registered with the Davaar Medical Centre in Dukinfield his records from Ann Street had been forwarded electronically. and The Court heard that whilst the medical records are sent electronically GPs not aware of which practice are sent to. The Court heard are known the details of the practice Mr Baddeley had that if the GP had registered with he would have spoken to them about his mental health issues and the fact that he longer to be under psychiatric services and was not receiving his appeared no medication (Save for the one prescription issued OnOhee3o"Mgrch} anti-psychotic The Court also then heard from GP from the Davaar Medical Practice. advised the Court that due to the fact that medical practices He are on different computer systems; when Mr Baddelys' electronic records were received the fact that he was diagnosed with Schizophrenia was not obvious in the formatc were received. On the 18th May Mr Baddeley attended for & new patient check and Healthcare assistant; but this was limited and the was seen by Healthcare Assistant would not have been expected do have Coad alehrdeleatote records which had been received the electronic The Davaar Medical practice did not receive Mr Baddeleys written the 28th 2015,these were not reviewed until the asieyuneritleheecheds wetd reviewed were detailed as not requiring any action. were
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.