Matthew Edwards
PFD Report
All Responded
Ref: 2017-0451
All 1 response received
· Deadline: 11 Sep 2017
Response Status
Responses
1 of 1
56-Day Deadline
11 Sep 2017
All responses received
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Coroner's Concerns
1.Matthew Edwards was discharged from Tameside Hospital in February 2016. The discharge summary was not dispatched until July 2016. The evidence was that this was not a one off 'difficulty and that a significant backlog had developed with discharge summaries routinely being dispatched many months after discharge. As a result; Matthew Edwards GP was not notified about his period as an in patient: When he attended subsequent GP appointment; she was unclear about the discharge plan for Mr Edwards ad the rationale for it.
2. The follow up appointment was not made for Mr Edwards on his discharge: When the discharge summary was dispatched subsequently this was not picked up on and there was no system in place to ensure that follow up appointments had been booked prior to discharge:
3. There was a ofat least 1 week for a CT angiogram: This was due to a shortage of slots. As a result the diagnosis of a possible embolism was not ruled out at an early stage:
2. The follow up appointment was not made for Mr Edwards on his discharge: When the discharge summary was dispatched subsequently this was not picked up on and there was no system in place to ensure that follow up appointments had been booked prior to discharge:
3. There was a ofat least 1 week for a CT angiogram: This was due to a shortage of slots. As a result the diagnosis of a possible embolism was not ruled out at an early stage:
Responses
Response received
View full response
Dear Ms Mutch, Regulation 28: Report to Prevent Future Deaths, following the inquest touching upon the death of Matthew Robert Edwards The purpose in wriling is in respect of your letter, dated 17 July 2017 , and enclosure in the form of the Regulation 28 Report, issued following the conclusion of the inquest touching upon the death of Matthew Roberts Edwards, which concluded on 7 June 2017 . hope to be able to address the concerns raised in Section 5 of your report, and set out below my response, adopting the same numbering for ease of reference. Delay in completion of the discharge summary following Mr. Edwards' discharge Tameside General Hospital in February 2016 You will be aware of the Trust having previously responded to a Regulation 28 Report earlier this year, which was provided t0 you on 18 July 2017 following the inquest louching (he death of Derrick Lawrence Brocklehurst. have set out below for ease of reference my response lo your concerns in this respect and which hope is of assistance The Trust is aware of a historic issue with regard to the timely completion of discharge summaries in 2016 , and wish to reassure you that action has already been taken and progress made, in order to improve the situation in relalion to both the Emergency Department and the in-patient wards, and bring the expected completion rales and timescales wilhin those dictated by Trust policy: In order to the position back to a baseline from which (he Trust could confidently move forwards with new processes, extra resources were brought in to clear backlog that had regrettably developed with discharge summaries. wish to assure you that the Trust recognises the importance of discharge summaries as a handover of care between different organisations and services involved in the care of a patient: was disappointed to learn that a backlog had developed due to olher organizational pressures ad asked my executive team to lake immediate steps to identify the source of the problem and remedy it as swiftly as possible disability Everyone Matters confident Chief Executive James in EMPLOYER Chalrman Paul Coanellhn from bring fully Karen
NHS Tameside and Glossop Integrated Care NHS Foundation Trust The Divisional Director of Operations for Adult Medicine has been tasked with leading on this issue, with support from Brendan Ryan; Medical Director. The responsibility to ensure that every patient has discharge summary rests with the Consultant responsible for that episode of care, and this has been reiterated to all consultants. Compliance is monitored by the Trust's Service Quality Operational Governance Group (SQOGG); and the Clinical Directors and Directorate Managers are providing leadership on this issue to ensure (hat improvements are made and maintained. am advised that new process is to be put in place for the discharge of palients from the Emergency Department: The Trust is implementing its plan to introduce new bespoke software to enable the production of an electronic casualty card, t0 replace the current handwritten casualty cards produced by the team in the Emergency Department, This will mean , Ihat Ihe data from electronic casualty card will be used to create discharge summary which will be electronically sent to Ihe patient's GP practice in near real time: It is anticipaled that this will ensure that a discharge summary is completed for patient seen within Emergency Department wilhout increasing the burden on the clinical leams: As you will no doubt appreciale, (his is a significant piece of work which will revolutionise the way in which the Emergency Department operates. The bespoke software is currently being finalised and the Trust plans to begin the roll out of the new electronic casualty card from October 2017 . The new electronic casualty card system will include a dashboard clearly identifying each and every patient discharged from the Emergency Department who has not had discharge summary completed, allowing Ihe management team to monitor and take action to ensure compliance_ The new process will also allow the Trust to monilor (he arrangement of follow up invesligations commissioned at the point of discharge from the Emergency Department The Trust has also introduced measures to improve Ihe process of discharge summaries in- patient wards. As mentioned above, additional resource was brought in to restore lhe position to a acceptable baseline. The Trust has also introduced increased managerial focus and monitoring of discharge summaries, with a routine 'safety net' email sent out to each Ward, identifying the number of discharge summaries outstanding for more than 48 hours, which is the timescale required under the Trusts Admission and Discharge Policy: The performance of each Ward is monitored by the Consultants responsible for the Ward, lhe Clinical Director and the Directorate Managers, to ensure Ihat the right level of resource is available to prevent a backlog before it occurs: am advised that all completed discharge summaries originating from both the Emergency Department and (he in-patient wards are sent lo the patient's GP practice electronically using the Hub System and Synertec. The current process is that discharge summary is created in the Trust's Electronic Patient Record (Lorenzo) , which is completed by Ihe doctor and finalised by the ward clerk before sent electronically to relevant GP practice overnight; and who in turn are required to acknowledge receipt of the discharge summary: A paper copy of (he discharge summary will also be provided to the patient in certain circumstances, for example, if Ihe patient is being transferred to another Trust, the Stamford Unit (a discharge to assess unit based on the grounds of Tameside General Hospital), a nursing, care or residential home facility, or if requested by the patient In addition to the completion of discharge summaries, the Trust also monitors the quality of discharge summaries. Regular audits of approximately 40 discharge summaries per month are carried out by the Trust's Chief Clinical Information Officer . The quality of the discharge summary is graded a excellent, good, poor or very poOr, with 93% per month deemed as excellent or good between February and August 2017 inclusive_ disability : Everyoneters confident Chlef Executlve Ibmc; in EMPLOYER chalrman Paul Connellan being key the the every yet from the being Kaccn
[HS Tameside and Glossop Integrated Care NHS Foundation Trust
2. That a follow up appointment was not made at the point of the discharge completed: This issue arose in the context of a particular and historical set of circumstances, in which a discharge summary was not completed for some five months following discharge: The junior member of medical staff compleling the discharge summary made a assumption thal the follow Up actions would have taken place some months previously, and which has since been acknowledged as an incorrect assumption: This was an individual human error, which has been the subject of reflection and development on the part of the junior member of medical staff concerned As consequence of the substantial improvements including the robust safety mechanisms incorporated into the discharge summary procedures as described in delail above, am satisfied and can reassure that the particular scenario that allowed this individual human error to be made, should not reoccur; 3 The delay of at least one week before & CT 'angiogram could be performed due to shortage of available appointments. It would appear that this issue may have arisen in part out of misunderstanding and which hope can clarify, and having confirmed the position with the Ambulatory Care Radiology Teams. On 21 September 2016 Mr: Edwards' presentation and Ihe results of investigations were suggestive of either chest infection Or pulmonary embolism , and appropriate prophylactic treatment was commenced at this point On return to the Ambulatory Care Clinic on 22 September 2016, CT angiogram was booked for the following week. It is important to emphasise that Mr. Edwards was not considered acutely unwell at this point in time and was on appropriate prophylactic treatment until such point as the CT angiogram confirmed or excluded either chest infection or pulmonary embolism The CT angiogram commissioned was for purely diagnostic purposes with appropriate treatment in place as at 22 September: The Ambulatory Care Clinic has two CT angiogram slots assigned per Patients such as Mr. Edwards who require a CT angiogram are assigned to the next available Ambulatory Care Clinic appointment and the CT angiogram performed' during (hat appointment: have included the current pathway in place for reference The view taken by the clinicians at the time was Ihat review and admission for CT angiogram the following week was appropriale. The Ambulatory Care Clinic and Radiology Manager have confirmed that had Mr: Edwards been acutely unwell on 22 September the CT angiogram have been expedited by a Consultant to Consultant discussion and no issue would have arisen with regard to availability of appointments. hope this clarifies the position and is of reassurance with regard lo the availability of ad access to this important diagnostic resource_ am very sorry that you had cause to issue this Regulation 28 Report ad would Iike to take this opportunity to emphasise that do take your concerns most seriously hope that have responded to your concerns and reassured you of all the work that the Trust has already undertaken and is currently undertaking, parlicularly in relation to discharge arrangements and procedures. Should you have any queries arising from the contents of this letter or require any further information or clarification, Ihen please do not hesitate to contact me at any stage
NHS Tameside and Glossop Integrated Care NHS Foundation Trust The Divisional Director of Operations for Adult Medicine has been tasked with leading on this issue, with support from Brendan Ryan; Medical Director. The responsibility to ensure that every patient has discharge summary rests with the Consultant responsible for that episode of care, and this has been reiterated to all consultants. Compliance is monitored by the Trust's Service Quality Operational Governance Group (SQOGG); and the Clinical Directors and Directorate Managers are providing leadership on this issue to ensure (hat improvements are made and maintained. am advised that new process is to be put in place for the discharge of palients from the Emergency Department: The Trust is implementing its plan to introduce new bespoke software to enable the production of an electronic casualty card, t0 replace the current handwritten casualty cards produced by the team in the Emergency Department, This will mean , Ihat Ihe data from electronic casualty card will be used to create discharge summary which will be electronically sent to Ihe patient's GP practice in near real time: It is anticipaled that this will ensure that a discharge summary is completed for patient seen within Emergency Department wilhout increasing the burden on the clinical leams: As you will no doubt appreciale, (his is a significant piece of work which will revolutionise the way in which the Emergency Department operates. The bespoke software is currently being finalised and the Trust plans to begin the roll out of the new electronic casualty card from October 2017 . The new electronic casualty card system will include a dashboard clearly identifying each and every patient discharged from the Emergency Department who has not had discharge summary completed, allowing Ihe management team to monitor and take action to ensure compliance_ The new process will also allow the Trust to monilor (he arrangement of follow up invesligations commissioned at the point of discharge from the Emergency Department The Trust has also introduced measures to improve Ihe process of discharge summaries in- patient wards. As mentioned above, additional resource was brought in to restore lhe position to a acceptable baseline. The Trust has also introduced increased managerial focus and monitoring of discharge summaries, with a routine 'safety net' email sent out to each Ward, identifying the number of discharge summaries outstanding for more than 48 hours, which is the timescale required under the Trusts Admission and Discharge Policy: The performance of each Ward is monitored by the Consultants responsible for the Ward, lhe Clinical Director and the Directorate Managers, to ensure Ihat the right level of resource is available to prevent a backlog before it occurs: am advised that all completed discharge summaries originating from both the Emergency Department and (he in-patient wards are sent lo the patient's GP practice electronically using the Hub System and Synertec. The current process is that discharge summary is created in the Trust's Electronic Patient Record (Lorenzo) , which is completed by Ihe doctor and finalised by the ward clerk before sent electronically to relevant GP practice overnight; and who in turn are required to acknowledge receipt of the discharge summary: A paper copy of (he discharge summary will also be provided to the patient in certain circumstances, for example, if Ihe patient is being transferred to another Trust, the Stamford Unit (a discharge to assess unit based on the grounds of Tameside General Hospital), a nursing, care or residential home facility, or if requested by the patient In addition to the completion of discharge summaries, the Trust also monitors the quality of discharge summaries. Regular audits of approximately 40 discharge summaries per month are carried out by the Trust's Chief Clinical Information Officer . The quality of the discharge summary is graded a excellent, good, poor or very poOr, with 93% per month deemed as excellent or good between February and August 2017 inclusive_ disability : Everyoneters confident Chlef Executlve Ibmc; in EMPLOYER chalrman Paul Connellan being key the the every yet from the being Kaccn
[HS Tameside and Glossop Integrated Care NHS Foundation Trust
2. That a follow up appointment was not made at the point of the discharge completed: This issue arose in the context of a particular and historical set of circumstances, in which a discharge summary was not completed for some five months following discharge: The junior member of medical staff compleling the discharge summary made a assumption thal the follow Up actions would have taken place some months previously, and which has since been acknowledged as an incorrect assumption: This was an individual human error, which has been the subject of reflection and development on the part of the junior member of medical staff concerned As consequence of the substantial improvements including the robust safety mechanisms incorporated into the discharge summary procedures as described in delail above, am satisfied and can reassure that the particular scenario that allowed this individual human error to be made, should not reoccur; 3 The delay of at least one week before & CT 'angiogram could be performed due to shortage of available appointments. It would appear that this issue may have arisen in part out of misunderstanding and which hope can clarify, and having confirmed the position with the Ambulatory Care Radiology Teams. On 21 September 2016 Mr: Edwards' presentation and Ihe results of investigations were suggestive of either chest infection Or pulmonary embolism , and appropriate prophylactic treatment was commenced at this point On return to the Ambulatory Care Clinic on 22 September 2016, CT angiogram was booked for the following week. It is important to emphasise that Mr. Edwards was not considered acutely unwell at this point in time and was on appropriate prophylactic treatment until such point as the CT angiogram confirmed or excluded either chest infection or pulmonary embolism The CT angiogram commissioned was for purely diagnostic purposes with appropriate treatment in place as at 22 September: The Ambulatory Care Clinic has two CT angiogram slots assigned per Patients such as Mr. Edwards who require a CT angiogram are assigned to the next available Ambulatory Care Clinic appointment and the CT angiogram performed' during (hat appointment: have included the current pathway in place for reference The view taken by the clinicians at the time was Ihat review and admission for CT angiogram the following week was appropriale. The Ambulatory Care Clinic and Radiology Manager have confirmed that had Mr: Edwards been acutely unwell on 22 September the CT angiogram have been expedited by a Consultant to Consultant discussion and no issue would have arisen with regard to availability of appointments. hope this clarifies the position and is of reassurance with regard lo the availability of ad access to this important diagnostic resource_ am very sorry that you had cause to issue this Regulation 28 Report ad would Iike to take this opportunity to emphasise that do take your concerns most seriously hope that have responded to your concerns and reassured you of all the work that the Trust has already undertaken and is currently undertaking, parlicularly in relation to discharge arrangements and procedures. Should you have any queries arising from the contents of this letter or require any further information or clarification, Ihen please do not hesitate to contact me at any stage
Action Should Be Taken
In my opinion, action should be taken to prevent future deaths and believe vou have the power to take such action:
Report Sections
Investigation and Inquest
On 5th October 2016 commenced an investigation into the death of Matthew Robert Edwards The investigation concluded on the 7th June 2016 and the conclusion was one of Narrative: Died as a result of a complication of aortic dissection for which hypertension is a recognised contributory factor: The medical cause of death 1a Cardiac tamponade secondary to haemopericardium;lbAortic dissection;Il Hypertension Matthew Robert Edwards had a history of hypertension and a family history of aortic complications. He was prescribed medication to assist with controlling his hypertension: As a result of side effects he stopped taking his medication. In February 2016 he was discharged Tameside General Hospital: discharge summary was sent to his GP in July 2016. As part of his discharge planning referrals were to be made for further investigations including echocardiogram: The referrals were not made: On the 17th September 2016 Matthew Robert Edwards attended Southport A&E complaining of chest pain. The preliminary view was of gastroenteritis but further tests were ordered_ Matthew Robert Edwards left the hospital before all of the results were available. He was not notified he had a raised troponin level. On the 21st September 2016 he went to A&E at Tameside General Hospital with central chest pain. A pulmonary embolism was suspected and he was referred for further tests. He was reviewed on the 22nd September 2016 and a CT angiogram was booked for the following from week. On the 25th September 2016 he was found dead at his home address, 25 Coombes Avenue; Hyde: CORONER'S CONCERNS During the course of the inquest, the evidence revealed matters giving rise to concern. In my opinion, there is a risk that future deaths will occur unless action is taken. In the circumstances, it is my statutory duty to report to you: The MATTERS OF CONCERN are as follows.
1.Matthew Edwards was discharged from Tameside Hospital in February 2016. The discharge summary was not dispatched until July 2016. The evidence was that this was not a one off 'difficulty and that a significant backlog had developed with discharge summaries routinely being dispatched many months after discharge. As a result; Matthew Edwards GP was not notified about his period as an in patient: When he attended subsequent GP appointment; she was unclear about the discharge plan for Mr Edwards ad the rationale for it.
2. The follow up appointment was not made for Mr Edwards on his discharge: When the discharge summary was dispatched subsequently this was not picked up on and there was no system in place to ensure that follow up appointments had been booked prior to discharge:
3. There was a ofat least 1 week for a CT angiogram: This was due to a shortage of slots. As a result the diagnosis of a possible embolism was not ruled out at an early stage: ACTION SHOULD BE TAKEN In my opinion, action should be taken to prevent future deaths and believe vou have the power to take such action: YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 11th September 2017 I,the coroner, may extend the period Your response must contain details of action taken or proposed to be taken, setting out the timetable for action: Otherwise, you must explain why no action is proposed. COPIES and PUBLICATION have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely_ father of the deceased, who may find it useful or of interest_ Iam also under a to send the Chief Coroner a copy of your response. delay ' duty
The Chief Coroner may publish either or both in a complete, redacted, or summary form: He may send a copy of this report to any person who he believes may find it useful or of interest: You may make representations to me, the coroner, at the time of vour response, about the release or the publication of your response by the Chief Coroner. Alison Mutch O.B.E HM Senior Coroner July 2017 17th
1.Matthew Edwards was discharged from Tameside Hospital in February 2016. The discharge summary was not dispatched until July 2016. The evidence was that this was not a one off 'difficulty and that a significant backlog had developed with discharge summaries routinely being dispatched many months after discharge. As a result; Matthew Edwards GP was not notified about his period as an in patient: When he attended subsequent GP appointment; she was unclear about the discharge plan for Mr Edwards ad the rationale for it.
2. The follow up appointment was not made for Mr Edwards on his discharge: When the discharge summary was dispatched subsequently this was not picked up on and there was no system in place to ensure that follow up appointments had been booked prior to discharge:
3. There was a ofat least 1 week for a CT angiogram: This was due to a shortage of slots. As a result the diagnosis of a possible embolism was not ruled out at an early stage: ACTION SHOULD BE TAKEN In my opinion, action should be taken to prevent future deaths and believe vou have the power to take such action: YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 11th September 2017 I,the coroner, may extend the period Your response must contain details of action taken or proposed to be taken, setting out the timetable for action: Otherwise, you must explain why no action is proposed. COPIES and PUBLICATION have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely_ father of the deceased, who may find it useful or of interest_ Iam also under a to send the Chief Coroner a copy of your response. delay ' duty
The Chief Coroner may publish either or both in a complete, redacted, or summary form: He may send a copy of this report to any person who he believes may find it useful or of interest: You may make representations to me, the coroner, at the time of vour response, about the release or the publication of your response by the Chief Coroner. Alison Mutch O.B.E HM Senior Coroner July 2017 17th
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.