Dear Mr Walsh Regulation 28 Response: Terence Ryan (Deceased) Thank you for your Regulation 28 report dated 8" September 2017. relating to the death of Terence Ryan took place on August 2017. I I understand that an inquest relating to Mr Ryan s death and have read your report: I have been fully advised of the circumstances am grateful to you for bringing these concerns to my attention to respond to the issues raised in your report and to advise youtof Iwould like to take this opportunity NHS Foundation Trust Trust") the actions already undertaken by Wrightington; Wigan and Leigh and the ongoing action In respect of this matter, that have the following concerns regarding the care provided to Mr Ryan: Iam aware you The evidence at the Inquest revealed that Wrightington; Wigan ad Leigh NHS Foundatioa Thesedoeg cothave a protocol with regard to patients who self-discharge from thechospiaio pariticdlaeiy wterevtheyproacbe recelving necessary medication te the foriieoftantd-chegalstoce the Deceased was identified as a vulnerable patient and the absence treatment; At the Inquest of a {protocol is even more important in relation to a vulnerable to contact the Police; General Practitioner; family or Social Services to There is no protocol self-discharged so that they become aware and bring it to their attention that a patient has that he has theycan make contact with the patient following his discharge to ensure appropriate support and necessary medication: Chairman: Robert Armstrong Chief Executive: Andrew Foster CBE 24th ("the patient: 1 OISABLSY

have requested that the Trust conduct a review of I appreciate that; in light of these concerns vou: policies; procedures and protocols in relation to: vulerable patient; who self-discharges from the hospitae withoet Patients, particularly a including doctors, can be aware of the necessary medications 50 that all Health Professionals; circumstances similar to the protocols If a self-discharges from the hospital in Deceased_ that the Trust does have a Policy for "Sel-discharge Agalnst Mecica? Advice" Please can I assure you This version of the Policy was approved in [enclose a copy of this policy for your information; was treated at the Trust: November 2014 and was in place at the time that Mr Ryan self-discharged against medical advice and Ieft the Iam aware that on 10th November 2016 Mr Ryan medication; When Mr Ryan had expressed a hospital without waiting for a discharge notice or this the reason for the desire to self- desie to selfe-discharge the doctor attended and tried toiestablish with Mr Ryan and explained the dischargeserhe doctor discussed the treatment and mobilisatovrplar initially agreed to stay, particularly in light of his history of DVT Mr Ryan need to stay in hospital, Onforsnes that Mr Ryan had decided to leave against however later the same the doctor was medical advice and had ieft without his medication: 2016 there is no record gfany contact with the Ge Following Mr Ryans discharge on Jth November acknowledges that this was not an and no discharge letter was sent to his GP,tThe Trust policy. and represented a failure to comply with the Trusts own standard of care Medical Advice states at paragraphs 4.4 and 4.5: - The Policy for Self-Discharge Against
4.4 Consultant/Clinical Team are responsible for: The Consultant or other clinicians In the team associated with the self-discharge
4.41 'Utilising this policy to support and minimise the risks of any patient In their care medical advice discharge and address the reason the patient is wishing to take their own
4.4.2 Establishing any issues that can be resolved. remaining in hospital and give the
4.4.3 Explaining to the patient the reasons/benefits for to make an informed decision: patient the relevant information In order for him/her mental health and ensure 4,44 Being aware of any concerns expressed regarding a patientsc self-harm harm to health assessment has been carried out if issues such a5 mental other has been identified. completed EPR discharge letter
4.4.5 Ensuring that all patients who self-discharge have a sent to the patients GP,
4.5 Ward Manager/Senior Nurse/ Nurse in Charge responsibility to: The Ward Manager/Senior Nurse/Nurse in charge has & with the discharge
4.5.1 Jutiliserags policy to support and minimise the risks associated Of any patient in their care against medical advicei in the team when a patient
4.5.2 Immediately Inform the consultant or another clinician expresses a wish to self-discharge against medical advien andfor information "co-ordinator/manager out-of-hours when advice _
4.5.3 Contact the site regarding self-discharge process Is necessary; discharge and address Establish the reason for the patlent wishing to take their own 4,5.4 any issues that can be resolved: patient day acceptable" against self-t

the benefits of remaining in the hospital to the
4.5.5 In conjunction with the doctor explain in order for the patient to make an informed decision: his/her own
4.5.6 Envoive Ifamil ad friends to try and dissuade the patient taking Gsclvegemtnisnust only be done with the consent or theoleteerar in the the details of the discharge process Is completed and filed
4.5.7 Document patients' medical records. possible that the has taken their
4.5.8 Inform their direct line manager a5 soon as _ own discharge:
4.5.9 Report this as an incdent via the Trusts DATIX 10" November 2016 did try to establish his reason for wanting The doctor who reviewed Mr Ryan on he did explain to Mr Ryan the to self-discharge to try to address anysunderlvid9ricerhi heith thexpelevant information to enable reasons/benerits for him staying In hospital and him and associated risks to hemsoos/aeeerh imormeddecision ce also explainedthee roerscon5 oPlictioelf-archargeclabticyisn belf-dschargengainst cedicaladvice cherebocisteg teh tneisonaiochaegeeordiset against and minimize the risks associated with the extent; to support medical advice doctor nor the nurse were aware of the Trusts policy However_ I appreciate that neither the treating it may be that the necessaly adehie is unacceptable: Given the laan 9 statugeeas irerbleliPatiertal beai5o eccepted that there : conslderationacas not given to Mr Ryan s status as a vunerable Mr Ryans GP, as required under %assideadlure to complete an EPR discharge letter and send thesto The failure to comply policy and in fact; as is required for alkpatients 0 bschatre standard: the self-discharge ad resuftedtin the provision of care below the expected with this policy is unacceptable Bulletin with the 'requirements of the Policy for Self-Discharge Against Ihave been informed that a bulletin elinecians and for the nursing staff to heighten awareness Medical Advice has been prepared for both been and will be shared [communicated in ofethe policy and ensure compliance: This information has the following ways: In respect of clinicians: for "Self-Discharge Against Medical Advice" was The requirements of the Trusts policy 18 October 2017. This meeting Is attended discussed at the Audit and Governance meeting on_ communicate this information back to senior clinicians and heads of departments who then by staff: the requirements of the Self-Discharge policyhas been The outcome of Mr Ryan's Inquest ad Committee (DQEC) Meeting which is communicated at the Divisional Quarterly Executive attended by senior clinicians have been on the agendas for all The bulletins with the requirements of the policy for cascading to all consultants. specialty meetings and sent to specialty governance leads= Consultants and Specialist An email has been sent from_ IMedical Director to all policy and the bulletin Asseciate doctors across the Trust enclosing a copy Of the seledisstanae communicate Ctequirerents of the policy Tor clinicians with a reguest that &ear of and with the key within their specialty to confirm that all are aware this information to all junior doctors are complying with the policy. patient _ against self- patient system: provide patient key put key

doctors' induction training and a copy of the policy The policy will be discussed at the junior for clinicians is to be emailed to all and [he document highlighting the key requirements doctors via the medical staffing coordinator; In respect of nursing staff: the bulletin with the requirements of the policy for nurses The self-discharge policy and meeting; this information then be has been on the agenda for the Senior Nurses cascaded down to all nursing by the senior nurses; nurses across the Divisions ofthis meeting an email has been sent to all the senior In advance bulletin with the requirements for nurses to heighten attaching the policy and the awareness and compliance with the policy: will be Included In the 5 point communication The Pollcy and the key requirements for nurses and all nursing staff will be required to foren Which is forwarded to all wards and departments have read the requirements of the completec a "sead and sign" document to ensure that theyt discharge: for what they are to do if a wishes to take their own policy Included in the News Brlef and Team Brief whicte shattnereiratede Both of these bulletins will also be eraif sent to all staff, I am aware that there will be toall staff Trust wide: The News Brief is a Weekly recommendations of the policy for_ tink tothese bulletins In this email to enable staff to ireview the presentation which is Against Medical Advice The Team Brieris temontheetigser bulletins = be Self-Discharge line managersto Staif at their monthivatamilf betcogirunc to at monthly crcorporacecefntoy thee Teanageer power point document and coibfzce mitnCatedequtemerts orthe incorporated the Trust to ensure awareness of and compliance with the = team meetings across policy: Self-Discharge Policy and Discharge Letters Hospital Information System (HIS) whichtes ar As you will be aware the Trust has now implentented 2 electronically through this system I electronic patient records Discharge Jetters areteenetatederectaniger lotegeive S dally list have been informed that as of the audit of this system, the This is a real time audit sO 02 Vne eatients for wihom a discharge summary has not beediscarletsdr can be sent to the actioe Qatiere sfaken to rectify this issue Immediately andta discarecfargearont the hoepital the is being dischargedjshortly after their discharge patients GP as summarylletter, the HIS does not distinguish In respect of the requirement for a discharge and those who have taken their own between patients who have been dischargedcby a doceot their GP and any failure or delay to Asesuch, all patients will have a discharge letter sent to dischdegehis wilbe pickediup by the Ward Manager and rectified provide medical coders, who attach a code to each to help In addition, I believe that the Trusts code to any who has self- 'patients to enable data to be collated, now assign self-discharge code categorise eachaonth an audit is conducted of the patients withea discharged: At the end of to each patients GP, For any patients without a to check that a discharge letter has been sent to the patients GP urgently. letter; the Division Is notified and a letter is sent discharge situation such as occurred in Mr Ryan's case will I trust that these provide reassurance that a not be repeated, junior key will put staff key patient point will staff system: pait patient system patient patient systems

The HIS system Is audlited and work Is currentiy being undertaken to developla thoresopkistrtrd Of the information recorded on HIS. As such the Trust is continually audit system to assess the quality patients. seeking to improve its systems to ensure the best care possible for its Continued action several changes have already been in place following Mr Ryan's sad death _ the As noted above following actions will be taken: - Information as to the requirements of the self-discharge policy will conttnue to be Coforanioateg to staff through the channels as outlined above to heighten awareness and ensure compliance with the policy: ensure that any failure to provide or a Development of the auditing of the HIS system to in in providing a discharge summary will be identified rectified in real time_ actions will be monitored via the Trust's Quality Safety Committee which is chaired by he above attended several members of the Executive team, including the Non-Executive Director and by Medical Director and Director of Nursing: Is a testament to how seriously the Trust considers the concerns raised by I hope the above response theit WIL has and will continue to leam lessons from Mr Ryans Mr Ryans death. I can reassiire you service we offer to our patients: care and the Trust is constantly seeking to improve the Please can I pass my sincere condolences to Mr Ryans family for their loss. comments or suggestions in relation to the proposed actlons above; I would be only If you have any too pleased to hear from you:

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