RESPONSE TO REGULATION 28 REPORT TO PREVENT FUTURE DEATHS Deceased: Derrick Lawrence BROCKLEHURST Date of death: 2 December 2016 Your ref: 5967/HC BACKGROUND On 6 June 2017 , the Chief Executive of Tameside Metropolitan Borough Council received a report Alison Mutch, OBE , Senior Coroner for the coroner area of South Manchester The report was made under paragraph 7 , Schedule 5 of Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013_ The report was made following the conclusion on 17 May 2017 of an investigation and inquest into the death of Derrick Brocklehurst (dob 23/07/1930, dod 02/12/2016). 3 matter of concern identified by the Coroner and directed to the Chief Executive of Tameside Metropolitan Borough Council was as follows; There was no documentation available of the carer visits The care provided and any issues with the provision of care could not be established. were not recovered by Social Services when care stopped. There was no system for recovery of care notes when care ceased. RESPONSE OF TAMESIDE METROPOLITAN BOROUGH COUNCIL Care Record Book In circumstances where Tameside MBC ("the Council") is required to meet the needs for care and support of an adult in its area, one of the ways it can do so is by providing domiciliary care at the home of the adult or "service user" To do this the Council contracts with independent providers who are registered with and regulated by the Care Quality Commission as a 'homecare agency' 5_ The service user's care needs are assessed by a social worker or a assessor and this assessment is recorded on the Council's electronic care management system, IAS 6_ The social worker or assessor, following consultation with the service user, any family members or carers for the service user and any other relevant persons such as Moving and Handling Officers would then prepare support plan detailing the type and nature of the care to be provided_ Once this support plan is authorised it, together with any other relevant information, is sent to an independent care provider commissioned by the Council to provide the care to the service user. Having regard to this information the provider carries out and records assessments of the service user'5 mobility, risk of falls , nutrition, skin integrity, environmental risks and other such matters This information enables the provider to formulate the actual care to be provided to the service user in their home: Regulation 17 of the Health ad Social Care Act 2008 (Regulated Activities) Regulations 2014 requires the provider to maintain securely a accurate, complete and contemporaneous record in respect of each service user , including a record of the care and treatment provided to the service user and of decisions taken in relation to the care and treatment provided from They

9 The "Helping People To Live At Home Service And Extra Care Support Service" contract between the Council and each care provider states at part 7.2.12 "The Provider will ensure care record book is introduced within the individual Service Users' homes: The Provider will be responsible for ensuring the information within the care record book (including information provided by the Commissioner andlor CCG in relation to Complex Care) is kept safe, is up to date and appropriate records are maintained by its staff
10. provider does this by completing the 'care record book' which includes relevant documentation such as the care plan, the above mentioned assessments with reviews and updates, Medication Administration Records (MAR): weekly meals records, food and fluid charts, weight charts , and any other relevant information. Daily 'running sheets' would record the to visits of carers, the tasks completed and any issues such as a refusal ofthe service user to take medication. The care record book will contain sufficient information to allow a carer to visit the service user and provide the necessary support that the service user has been assessed for; Records are required to be thorough and document any concerns or safeguarding issues that the carer may have. The care agency is required to notify the Council of any such concerns or issues. Monitoring by the Council of the Care Provided to Service Users 11_ The Council has a contractual right to request sight of all information within the care record book: Part 11.5.3 of the Helping People To Live At Home Service And Extra Care Support Service" contract states a provider must "comply with all reasonable requests relating to the performance of any aspect of the Services, including those areas that demonstrate the Providers ability to ensure this Agreement is complied with, such information t0 be returned to the Commissioner (or the CCG in relation to Complex Care) within 14 calendar days of the request'
12. The social worker for the service user completes reassessment of the need of the service user six weeks after the commencement date of care being provided. This is to ensure that the care and support is appropriate and meeting the assessed needs_ Subsequent reassessments are carried out depending on the complexity of case_ An annual review is also undertaken by the social worker In carrying out any reassessments or reviews the social worker will consider the care record book to establish that the required care is being provided and to identify whether there are any issues with this care. 13 In addition to this monitoring of the individual service user, the Commissioning Team undertakes monitoring of provider by way of a minimum of two validation visits every year and two contract performance visits per year: The validation visits focus on the provider's recruitment and selection policies and procedures, and the training of employees In addition a number of service user files are randomly sampled to ensure have the appropriate information contained within: 14 The contract performance visits look at any issues raised from the validation visits, as well as focussing on other issues such as complaints, matters raised by the provider or social workers, safeguarding investigation outcomes and the steps that have been recommended following safeguarding investigation: Additional unannounced visits can also be implemented should it be deemed necessary following a complaints or concern:
15. If the Council had concerns that records were not being completed or that a support plan was not being followed the Council's Adult Services would in the first instance investigate following which the care agency would be advised of the steps required and the time for compliance_ A recommendation may also be made that care agency staff be provided day day the the they

training Adult Services would work closely with the Commissioning Team and performance would be closely monitored. 16 The purpose of monitoring following concerns regarding record keeping would be to encourage providers to improve performance to a acceptable level: The Council will support providers to do this_ Should the Council continue to have concerns with provider's ability to maintain accurate records it can take further action such as issuing contract default notice and, ultimately, terminating the contract: A default notices could be issued in circumstances where there has been persistent breaches or for a more serious breach (normally identified via safeguarding) that has put a service user at serious risk: System for Recovery of Care Records 17 . When the care provided to service user is to be stopped the Council will notify the provider of this: The reason for ceasing care and support are varied but typically would be because the service user has died, moved to residential or nursing care or been in hospital for a period of time exceeding 3 weeks. Users and their families can also decide to stop receiving care and make other arrangements themselves. Once the care is stopped the provider is notified by the Councils Home Care Commissioning Team and the provider is then required to recover and archive the care records that have been maintained in the user's home. The Care Quality Commission requires a provider to store this information for years from the last date of entry on records. Each provider has its own procedures for recovery and retention of records: In preparing this report inquiries were made of the provider which last provided care to Mr Derrick Brocklehurst. That provider advised that its procedure is for the last care worker to visit the service user to recover the care book &d other records. These records will then be returned to the provider and placed in numbered box which is then sent to a central archive depot The local office of the provider maintains a register of archived boxes so that records can be retrieved if necessary: 18 There will be circumstances where the Council and the provider receive no prior notification of care ending (such as when a service user is admitted without notice to hospital and subsequently dies): In such circumstances the provider will be notified by the Home Care Commissioning Team that care has ended. The provider must take steps to try ad recover the care record book The provider will rely on the cooperation of whoever may still be residing at the service user's home, such as family members and others, to recover the care records. However if cooperation is not forthcoming the provider cannot enter the property to recover the records knowing that the service user isn't present and that the contract to provide care has ended:
19. In these situations the provider may not be able to recover the care record book. This will not mean that the provider has no records whatsoever. The provider is required to keep copies of the care plans and assessments which were carried out In addition the provider is required at regular intervals to obtain copies of other documents such as the MAR weekly meal records, daily running sheets and all other documents which are updated by carers on their visits to the service user. However it will mean that on occasions the provider will not be able to recover these updated records for the period when copies were last taken to the period when care ended without prior notification. Records relating to Derrick Brocklehurst
20. The Council accepts that the records detailing the care provided to Mr Brocklehurst for the period 31 October 2016 to 17 November 2016 when care ended had not been recovered by the provider and were unavailable for the Coroner conducting the inquest. 21_ From 31 October 2016 the provider of care to Mr Brocklehurst had changed following the Council terminating its contract with the previous provider. The provider had not in that the from

relatively short time made copies of documents recording the daily care given in that period. 22 On 10 November 2016 the new provider contacted the Council with concerns that Mr Brocklehurst wanted to terminate his care. A Council Officer together with manager employed by the provider visited Mr Brocklehurst on 16 November 2016 when he and his wife indicated that they wished for care to end: It is clear from the Councils own reassessment document, updated by the Council Officer on 17 November 2016, the care record book was updated. She records that she "looked at the care record book and minimal tasks are being provided: Derrick does not like the carers supporting with his personal care and prefers his wife to undertake this
23. The provider last visited Mr Brocklehurst on 21 November 2016 following which his care was ended in accordance with his wishes_ The provider was formally notified of this on the 22 November 2017,
24. It is accepted at this point the provider should have made arrangements t0 recover the care record book; This was not done_ On 28 November Mr Brocklehurst was admitted to hospital where he remained until his death on 2nd December. Again it is accepted that the provider did not make any arrangements following Mr Brocklehurst's death to recover and consequently had no record of the care it had provided since taking over the contract on 31 October 2016. 25 Efforts were made by the Council in advance of the Inquest to recover the Care Book from However it appeared that the care book had been discarded by Jin February 2017 during 'de-cluttering' of the property she had shared with her husband; CONCLUSION 26_ The Council regrets that no documents relating to the care visits were available to the Coroner. However the Council believes that this was an isolated incident rather than a example of a systemic failing and it is only very rarely that a care provider is unable to provide to the Council when requested the actual care record book a service user'$ property_ 27 Care Providers are under both a regulatory and contractual obligation to maintain accurate and up to date records of the care provided to a service user. Enquiries with the provider responsible for Mr Brocklehurst's care have established that the provider was aware of these responsibilities and also had procedure for the recovery and archiving of care record books following the termination of care. However to minimise risk of a provider failing to recover a care book following the termination of care the Council has taken or proposes to take the following steps: The agenda for a Provider Forum, due to take place on 25 July 2017 , included an item relating to Care Record Books. Unfortunately this forum was postponed. The item will be included on the agenda for the next Provider Forum at which providers will be reminded of their obligations and in particular the obligation to; maintain accurate records; regularly obtain copies of documentation contained in the Care Record Books which is updated on a dailylweekly basis such as, but not limited to, daily running sheets, MAR, weekly meals records, food and fluid charts, weight charts, and any other relevant information;
iii. make adequate arrangements to recover Care Record Books when notified that care is to be or has been ended; iv record the reason for failing to recover a Care Record Book; the being from the

archive the Care Record Book and any other records for a period of years from the last date care was provided. Following the Provider Forum above points will be confirmed in writing to all providers; With immediate effect on a weekly basis the Homecare Commissioning Team will run report detailing which service users have ceased to receivve care_ The relevant provider will be sent copy of this report with request for confirmation that the care record book has been recovered the service user. Where the provider states records cannot be recovered the provider must notify the Council; detail the attempts that have been made to recover the records and give reasons for not able to do s0; Where a provider has been unable t0 recover a care record book the matter will be raised and discussed with the provider at contracts performance meeting: If necessary and appropriate to do so the Council will require the provider to take steps and measures to address the failure t0 recover record book: 28_ The Council trusts that these actions and proposals are sufficient to satisfy that Coroner that the Council does take this issue seriously, that there is system in place for the recovery of care record books and that care providers will be advised of their record keeping obligations: This in turn will minimise the risk of care record books not being available at future Investigations and Inquests.

Dear Ms Mutch Regulation 28; Report to Prevent Future Deaths following the inquest touching upon the death of Derrick Lawrence BROCKLEHURST write further to your letter dated 5 June 2017 enclosing Regulation 28 Report issued at the conclusion of the inquest touching upon the death of Derrick Lawrence BROCKLEHURST, which took place on 17 2017 , hope to be able to address your concerns, as set out in Section 5 of the Regulation 28 Report, and adopt the same numbering for ease of reference_ 2 No discharge summary was provided by Tameside General Hospital to the GP after the deceased was seen in A and E The Trust is aware of a historic issue with regard to the timely completion of discharge summaries in 2016 and wish to assure you that action has already been taken, and progress made, in order to improve the situation in relation (0 both Emergency Department and the in-patient wards, and bring the expected completion rates and timescales within those dictated by Trust policy: am sorry if the action which the Trust has taken to date was not clearly available to you the course of the inquest and you could not be reassured that the Trust had fully identified the issues and put a robust plan in place t0 improve the situation. In order to the position back to a baseline from which the Trust could confidently move forwards with new processes, extra resource was brought in to clear backlog that had developed with discharge summaries: wish to assure you that the Trust fully recognises the importance of discharge summaries as a handover of care between different organisations and services involved in the care of patient: was disappointed to learn that backlog had developed due to other organizational pressures and asked my executive team to take immediate steps to identify (he source of the problem and remedy it as swiftly as possible Divisional Director ol Operations for Adult Medicine has been tasked with leading on this issue , wilh support from Medical Director. The responsibility to ensure that every patient has discharge summary rests with consultant responsible for that episode of care and this has been reiterated to all consultants Compliance is being monitored by the Trusts Service Quality & Operational Governance Group (SQOGG) and the Clinical Directors and Directorate Managers are providing leadership on this issue to ensure that improvements are made am advised Ihat new process is to be in place for the discharge of patients from the Emergency Department; The Trust is planning to introduce new bespoke software to enable the production of an electronic casualty card, to replace the current handwritten casualty cards produced by the doctors and nurses in the Emergency Department: The data from the electronic casualty card will be used t0 create a discharge summary which will be electronically sent to the patient's GP practice It is anticipated that this will ensure that a discharge summary is completed for patient seen within the Emergency Department disability without unduly increasing the burden on the doctors Everyone confident Chlef Executlve Karen James Matters EMPLOYER Chalrman Paul Connellan May the during bring the put key every

[HS Tameside and Glossop Integrated Care NHS Foundation Trust As you will no doubt appreciate, this is a significant piece of work which will revolutionise the way in which the Emergency Department operates The bespoke software is currently being written 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 that has been discharged from the Emergency Department but has not had a discharge summary completed, allowing the management team to efiectively scrutinise compliance. The new process will also allow the Trust to monitor the arrangement of follow up investigations commissioned at the of discharge from the Emergency Department which will further improve patient safety: Although not directly relevant in the context of this Regulation 28 Report would like to advise you that the Trust has also introduced measures to improve the situation in terms of discharge summaries from in-patient wards. As mentioned above, additional resource was brought in to bring the position back to an acceptable baseline_ The Trust has also introduced increased managerial and monitoring of discharge summaries, with '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 by the Trust's Admission and Discharge Policy: The performance of each ward is monilored by the consultants responsible for the ward, the Clinical Directors and the Directorate Managers to ensure that 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 the in-patient wards are sent to the patients GP practice electronically using the Hub System ad Synertec. The current process is that discharge summary is created in the Trust s Electronic Patient Record (Lorenzo) , this is completed by the doctor ad finalised by the ward clerk before being sent electronically to the relevant GP practice overnight who are required to acknowledge and receive the discharge summary: A paper copy of the discharge summary will also be provided to the patient in certain circumslances, 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 Hospilal) a nursing, care or residential home facility, or if requested by the palient: 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 as excellent, good, poOr or very poor, with 93% per month deemed as excellent or good between January and June 2017 inclusive_ The Trust has received 9 incidents related to discharge summary quality from approximately 37,000 discharge summaries; an incidence rate of less than 0.03%_ Whilst understand that the following area of concern was directed at Tameside Metropolilan Borough Council, this issue is relevant to the Trust as a provider of community services and wanted to take the opportunity to address you on the Trust's work in this area There was no documentation available of the carer visits The care provided and any issues with the provision of care could not be established. They were not recovered by Social Services when care stopped There was no system for recovery of care notes when care ceased In addition, the Trust is aware that you have previously issued a Regulation 28 Report to Stockport NHS Foundation Trust in relation to Ihe retention of a central contemporaneous set of notes by the District Nursing Service and retrieval of those notes following the death of a patient: The Trust is keen to adopt a proactive approach and demonstrate leaming from issues which arise not only in relation to the care of its patients, but also learning from the wider health economy, and other organisations_ disability Everyoneters confident Chlet Executlve Karen James in EMpLoyER Chalmman Paul Connellan yet point focus very

NHS Tameside and Glossop Integrated Care NHS Foundation Trust The Trust's District Nursing Service, which covers the Tameside and Glossop locality, has recently amended the process in relation to note keeping and strengthened the process for retrieval of notes am advised that the old process was similar to that adopted by Stockport NHS Foundation Trust in that carbonated evaluation sheets were used to record findings a home visit. However, the Trust identified that this represented a concern in that the central set of notes may not be up to date and important information about a previous visit may not be available to the district nurses at base. It was considered essential to have central contemporaneous set of notes particularly for complex cases where a patient's care needs may be constantly evolving; in view of the fact that the district nurses work as a team and not allocated specific patients due to shift patterns and fluctuating visit requirements. A comprehensive handover of care between staff is imperative to ensure a consistent and holistic approach to the care of each individual patient in this setting: The new process requires separate carbonated evaluation sheet to be completed for each and visit (excluding those for routine insulin or low molecular weight injections) and brought back to base immediately thereafter so that it can be filed in the central notes. standard operating procedure has been produced and disseminated to all staff within the District Service out new process and compliance will be monitored by the Team Leaders. am advised that the District Nursing Service also use "Team Time" for the handover of important information between staff. Team Time takes place each and is used as a mechanism for staff to highlight any problems or issues that encountered the morning: It is also an opportunity for the Team Leader; who is responsible for leading Team Time, to understand the workload of the team and to reorganise the workload if necessary. A record of the handover provided "Team Time" is documented, signed by the Team Leader and retained centrally at base but not placed in a individual patients notes as this could contain confidential information in relation to another patient If follaw-up tasks are allocated during Team Time, such as increasing the frequency of visits or making a referral t0 another service, these remain the responsibility of the district nurse that attended on the patient on the last occasion, unless specifically re-allocated to another member of staff. am very sorry that you had cause t0 issue this Regulation 28 Report and would like to take this opportunity to emphasise that do take your concerns 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 in relation to discharge arrangements understand that meeting has been arranged for 30 August 2017 with the Trust $ Medical Director, and Director of Quality Governance, John Fletcher at which these issues can be further discussed, if required: Should you have any further questions arising from the contents of this letter, please do not hesitate to contact me