From Dr Dan Poulter MP Parliamentary Under Secretary of State for Health Department Richmond House of Health 79 Whitehall POC5 873078 London SWIA 2NS Mr J Pollard Tel: 020 7210 4850 Senior Coroner Coroner' s Court 1 Mount Tabor Street 1 0 JUL 2014 Stockport SKI 3AG Dzz/ W Quecch Thank you for your further email of June 2014 in response to our reply of 11 June 2014 about the Regulation 28 report into the death of Audrey Lily Kelly: In your email you requested that I contact you when Stockport Clinical Commissioning Group (CCG) had completed the further investigations that were outlined in my original response as follows: Stockport CCG are currentiy investigating this matter further;, specifically regarding the attempted access to tae record at the time. Although their technical audit of the Stockport Health Record (SHR) showed no attenpted access the relevant times, this could be explained by a break in connection between the SHR &nd Mastercall' $ clinicel The CCG are working with suppliers to attempt to understand exectly the Ioot cause and whether it was & human or system eTor; The CCG have also written to Mastercall to axange a meeting to understand the issues mole fully, and improve processes for the reporting of issues relating to the SHR My officials have now been in touch with Stockport CCG about your further request: Ican confirm that Stockport CCG has now undertaken further investigations involving the GP out ofhours provider Mastercall, to ascertain exactly why access to the shared patient record for Audrey Kelly failed. Mastercall report that the nurse who had been unable to access the was a new member of staff and had not yet been provided with an NHS smartcard. As a result; she was unable to access a shared Stockport Health Record, The nurse however continued with the diagnosis by asking for medical history: 12th _ again auring system. system

Mastercall have confirmed that all relevant members of staff now have an NHS Smartcard, In addition, Mastercall have confirmed that their mobile practitioners, who carry out home visits, do not have access to patient records from their mobile 'Toughbook' computing devices: Hence; when the GP visited the patient's home, the GP also did not have access to the health record and the information it contained regarding allergies Stockport CCG is already enagaged in continual improvement work in this area. However; as a result of this investigation; the CCG is also planning the following measures: to seek formal assurance from Mastercall about processes for new starters and contingency plans for when practitioners do not have Smartcards. to work with Mastercall to map and analyse processes and systems in place for accessing shared records. This should enable the CCG to identify and mitigate any further risks to work with Mastercall to ensure that it has fit for purpose mobile solutions in the future; with access to the right information at the point of care: This will be managed as part of a project improvement plan reporting through the CCG'$ governance structure. [ hope that this further response is helpful and once I am grateful to you for bringing the circumstances of Mrs Kelly's death to my attention: Bk h DR DAN POULTER again

From Dr Dan Poulter MP Parliamentary Under Secretary of State for Health Department Richmond House 79 Whitehall of Health London SWIA 2NS POC5 855166 Tel: 020 7210 4850 Mr J Pollard Senior Coroner Coroner' s Court 1 0 JuN Z014 1 Mount Tabor Street Stockport SKI 3AG 0eet NV PJe-J Thank you for your letter following the inquest into the death of Audrey Lily Kelly. In your report conclude that the medical cause of death was acute myocardial insufficiency, coronary artery atheroma and systemic hypertension. On 17th November 2013 Mrs Kelly complained of abdominal and the out ofhours (OOH) doctor attended. He was unable to access her GP medical notes and s0 was not aware that she had an to the antibiotic Trimethropim: He prescribed this same antibiotic and she took three of the tablets as prescribed. She was then found dead at home two later. Although the initial concern was her consumption of these tablets to which she was allergic, it turned out that she died of natural causes. You raise the following matters of concern: The OOH doctor and nurse who took the call at the Stockport OOH service could not obtain the electronic patient notes held by the patient'$ own GP. The senior administrator of the OOH service also confirmed that neither he nor the hospital emergency departments had direct access to GP notes. You state that this lapse in procedures will inevitably lead to further lives being lost and you consider there is an immediate need for directions to be issued to all out of hours providers and the appropriate Clinical Commissioning Groups to the effect that there must be free and unfettered access to all the GP notes in such circumstances. Currently, there is a national system in place that allows access to information from GP records by healthcare staff working in urgent and emergency care settings This is the Summary Care Record (SCR) which has been developed by the Health and Social Care Information Centre (HSCIC): you pain allergy - days system

The SCR is an electronic record which contains key information relating to an individual patient such as their medications, allergies and adverse reactions The record may, with the explicit consent of the patient; contain additional information relating to their clinical needs. Data for the SCR is extracted directly from the GP record and is then held securely on an infrastructure known as the National Spine. SCRs can be viewed electronically by authorised healthcare staff providing urgent Or emergency care to patients, anywhere in England, any time of day 0r night; Viewing of the records is via a web-based SCR application which is both relatively cheap and easy to implement; Authorised healthcare staff are issued with their own individual SmartCard to access the system These SmartCards are configured to include role-based access controls so that only healthcare staff who can demonstrate a legitimate relationship to the patient can access the clinical information in the SCR. In addition, any accesses that are made to the records are potentially auditable. Currently (April 2014) 37.5 million people in England have Summary Care Records (66% of the population) and the number of SCRs is increasing at a rate of approximately 200,000 each week: From 1 April 2014, GP practices are contractually required to provide an automated upload of their summary information on at least a daily basis to the Summary Care Record, or have a published plan in place to achieve this by 315 March 2015. This requirement is a result of contract negotiations between the BMA '$ General Practitioners Committee (GPC) and NHS Employers (on behalf of NHS England) on changes to the General Medical Services contractual arrangements in England from April 2014. The NHS Standard Contract; mandated by NHS England for use by commissioners for all contracts for healthcare services other than primary care, also stipulates that: the Provider must ensure that all Staff involved in the provision of urgent care are able to view Service User information from GP records, whether via the Summary Care Records Service or a locally integrated electronic record system. (NHS England December 2013) In addition, there are other commercially available solutions for sharing patient clinical information: Some GP IT system such as TPP SystmOne and EMISweb are working with local health communities to implement local solutions for key suppliers

sharing clinical information from the GP record with clinical staff in organisations which provide urgent and emergency care away from the patient'$ GP surgery: With regard to the local position in NHS Stockport Clinical Commissioning (CCG), Ican confirm that SCRs have s0 far been created for 34% of registered patients at 28% of their GP practices This percentage is significantly impacted by the availability of SCR compliant GP systems within NHS Stockport CCG. However; NHS Stockport CCG plans to progress SCR uploads across the local GP practice community. The SCR roll out will be supported by GP systems migrating O' attaining SCR compliance. In addition, HSCIC will provide significant resource and support to local NHS organisations in Stockport when SCRs reach a certain level (circa 50 60% of local patient population). Iam pleased to report that a number of organisations are already successfully utilising and realising the benefits of SCR across the Greater Manchester region, including those listed below: Royal Bolton Hospital Bury OOH NW Manchester OOH Fairfield General Hospital Royal Albert Edward Infirmary Wrightington Hospital Oldham OOH The Royal Oldham Hospital North Manchester General Hospital" Stockport also has a local health record solution (Stockport Health Record) which is limited to staff and patients within NHS Stockport only and provides access to clinical information in the Patient'$ GP record such as test results, medications, allergies and social care Or mental health information relevant to the patients' medical care. The health record is kept on a secure database that is maintained by NHS Stockport CCG and is never sent to other areas outside the health and social care system: Access to the record is restricted to professionals with a duty of care to the person and is only accessed through the secure NHS Network at the of care_ So, for example when a patient is registered with Stockport GP Practices, information concerning any allergies may have can be accessed from their health record when attending the Emergency Department at Stepping Hill hospital (Stockport NHS Foundation Trust) or when calling the local GP Out of Hours provider (Mastercall), providing the patient has not dissented to local record sharing: Group point they

This local approach to sharing care records has been highlighted as national exemplar and was a successful DH Common Assessment Framework (CAF) demonstrator site. However; I acknowledge that none of the above explains why neither Mastercall nor the hospital emergency department could access Audrey Kelly's GP records on the day in question. My officials have therefore contacted the Stockport CCG about this case_ The CCG has confirmed that both Mastercall and local hospital departments and emergency departments have access to view summary shared GP records for patients in all but one Stockport GP practice, through the Stockport Health Record (SHR) system: The final outstanding practice is yet to sign a data sharing agreement; but has verbally agreed to share data in the meantime. On the day in question; Mastercall staff accessed shared patient records for Stockport patients, on over 40 occasions. The CCG have confirmed that Audrey Kelly had a shared record which was available to view and which included her to the antibiotic specified in your report Mastercall have stated that at 14.06 on the day in question; tried and failed to access the patient's record on the SHR. However, audit data from the SHR does not show any activity between 13:19 and 14.48. Stockport CCG are currently investigating this matter further, specifically regarding the attempted access to the record at the time. Although their technical audit of the Stockport Health Record (SHR) showed no attempted access the relevant times, this could be explained by a break in connection between the SHR and Mastercall's clinical The CCG are working with suppliers to attempt to understand exactly the root cause and whether it was a human or error: The CCG have also written to Mastercall to arrange a meeting to understand the issues more and improve processes for the reporting of issues relating to the SHR Ican also report that there are plans to further develop an integrated records solution in Stockport. The CCG has recently implemented plans for wider access and increased multi organisation record sharing to support integrated care models As of wider service reform plans, the CCG is also in discussions with suppliers and providers around sharing access to the full GP record (including any free text contextual notes) allergy - they - during system. system fully, part

1 that this response is helpful and 1 am grateful to you for bringing the circumstances of Mrs Kelly' s death to my attention. Ont M DR DAN POULTER hope