Dear Dr Julian Morris

Mr Harold Chapman came under the care of the Heart Hospital (University College London Healthcare Trust) in 2009 following a diagnosis of hypertrophic cardiomyopathy. Following the merger of the Heart Hospital with Barts Health Trust cardiac services in 2015 his care was transferred to Barts Heart Centre.

The Inherited Diseases service at Barts Heart Centre (BHC) manages up to 10,000 outpatient episodes per year and manages elective and emergency inpatients. The team includes a core group of 6 consultants, 5 clinical nurse specialists, 2 genetic counsellors, and 3 dedicated clinical fellows along with variable numbers of research fellows and training SpRs. Each week, the team complete more than 40 clinics, of which half are face-face with the consultant.

At diagnosis, Mr Chapman’s condition was assessed as low risk, and this situation remained through to 2015 when he was first seen at BHC. At this time his test results, along with his clinical symptoms, indicated an increase in risk that should have led to referral for an Implantable Cardiac Defibrillator (ICD) but this was not recognised by the clinicians involved in his care. In April 2016 his risk was formally assessed and he was referred to the multi-disciplinary team meeting for consideration of ICD implantation. There was a considerable backlog with the MDT at that time, the waiting list for discussion was 2-3 months. Mr Chapman made efforts to chase the team, mainly through email correspondence with the clinical nurse specialist, to gain a conclusion as to his need for an ICD but he sadly suffered a sudden cardiac death in June 2016 before the matter was concluded. A serious incident was reported by BHC following confirmation of the cause of Mr Chapman’s death. An investigation was led by Dr Saidi Mohiddin, a consultant with the inherited diseases team but not personally involved with Mr Chapman’s care. The investigation concluded that the root cause of Mr Chapman’s death was the failure to recognise and action the risk factors for SCD presented by the patient in 2015. At this time there were established guidelines for the assessment of the risk of sudden cardiac death, however there was no mandated local policy for use of a formal risk assessment tool.

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The service has taken action following the conclusion of the investigation to improve practice. This has included development of a procedural document detailing requirements for SCD risk assessment and pathways for escalation to the MDT meeting; adherence to this document is being monitored via the audit process. The MDT now meets twice weekly and the backlog has been cleared. The pathway document defines the acceptable interval between risk detection and presentation to MDT. A complaint was received from Mr Chapman’s widow in August 2016. This letter raised her serious concern with regards to the timeliness of care provided to her husband, insufficient risk assessment and lack of responsiveness when her husband was attempting to expedite his treatment. The site upheld Mrs Chapman’s complaint and offered a full apology. Following conclusion of Mr Chapman’s inquest in 2017, a request was received from his family to meet with the staff at BHC. This meeting, chaired by Edward Rowland, BHC Medical Director, was held on 22/11/2017. The team were able to offer the family assurance that lessons had been learnt from Mr Chapman’s death and practice had changed. One of the lessons learnt from the investigation of this incident was the need to ensure that email correspondence with patients must be added to the patient’s health record. The cardiomyopathy service has taken action to ensure that this is now done. More widely, clear guidance is needed for all clinicians on their responsibilities regarding email communication with patients. Trust wide guidelines are being drawn up, working to the following principles:
1. Emails sent to and from Barts Health clinicians from other clinicians and/or patients which contain clinically important information about Barts Health patients, must be filed in the patient case notes.
2. If Barts Health staff give an email address to patients, then that email box must be monitored and all e-mails should be seen and appropriately addressed, within a clinically acceptable time period. If such an email address is temporarily not monitored due to leave etc, then the out of office message should make this clear.
3. The Barts Health website will be reviewed to ensure that patients and referrers know how to contact the hospital. If email addresses are published, it will be made explicit when and if the address should be used for clinical correspondence.
4. Letters sent to patients and clinicians will routinely detail how the clinical team can and should be contacted.

From Caroline Dinenage MP Minlster ol State ITr Care Department of Health 39 Victoria Street London SWIH OEU Ref: 01620/2016 020 7210 4850 PFD-112324 Dr Julian Morris HM Assistant Coroner; Inner London South 2 2 FEB 2018 Southwark Coroner's Court 1 Tennis Street Southwark London SEI 1YD (V iano Thank you for your letter of 22 December to Jeremy Hunt about the death of Mr Harold Chapman, Iam responding as Minister with responsibility for professional regulation; Iwas very saddened to read of the circumstances surrounding Mr Chapman's death: Please pass my condolences to his family and loved ones 1 appreciate this must be a very difficult time for them, It was disappointing to learn that, in Mr Chapman'$ case, emails sent by Mr Chapman to his clinicians were not viewed or acted upon and no response was received by Mr Chapman. As you point out, patient contact with medical professionals is an important part of modern medical practice, and it is regrettable that this did not work well in this case. You ask about guidelines in respect of communication between patients and their clinicians My officials have made enquiries and am able to advise the following The General Medical Council (GMC) develops standards and guidance that doctors need to follow to deliver high quality, safe care The core professional standards expected of all doctors are set out in Good Medical Practice which covers fundamental aspects of a doctor'$ role, including communication with patients. Good Medical Practice was published in 2013 and describes what is expected of all registered doctors: All doctors must be familiar with and follow Good Medical Practice and the explanatory guidance Failure to follow the guidance set out in Good Your

Medical Practice may put a doctor'$ registration at risk Good Medical Practice is available at WWW= gmc-ukorelguidancelindexasp: The following guidance is given in respect of communicating with patients; Communicate effectively 31, You must listen to patients; take account of their views, and respond honestly to their questions:
32. You must give patients the information they want or need to know in a way they can understand You should make sure that arrangements are made, wherever possible, to meet patients' language and communication needs.
33. You must be considerate to those close to the patient and be sensitive and responsive in giving them information and support,
34. When you are on duty you must be readily accessible to patients and colleagues seeking information, advice or support. WWW gmc-ukorglguidancelgood_medical_practicelcomnunicate_effectively asp And; Communicating with patients
132. Wherever possible, you should communicate with patients in a format that suits them; For example, electronic communications such as email or text messaging _ can be convenient and can support effective communication between doctors and patients, with appropriate safeguards
133. Most communication methods pose some risk of interception for example, messages left on answering machines can be heard by others and emails can be insecure. You should take reasonable steps to make sure the communication methods yoll lise are secure: WWWogmc-ukorglguidancelethical_guidance/30624a8 In 2016,NHS England issued guidance using email and text message for communicating with patients a8 part of the Accessible Inforation Standard Although the guidance is intended to support the use of email and text message as part of communication with people who have & disability, impairment or sensory loss May ` for

Department of Health (in line with the scope of the Accessible Information Standard); the principles are applicable in general. Relevant passages include: The parameters of how much contact is conducted by email and / or text message should be agreed, with the service setting clear limits and ensuring that the patient or service user is aware of them. It is likely that the service will wish to limit two-way dialogue via email or text message which risks becoming a 'virtual consultation' and instead direct the patient or service user to make an appointment, for example to discuss test results; Services, and their staff, should only send emails from generic team accounts (for example diabetes@lginhs net _ oncology@cochnhs uk) and established corporate text messaging accounts: This ensures that patients / service users can be confident that the sender is legitimate Individual staff email addresses should not be used Use of generic accounts also ensures that emails and text messages can be accessed and actioned by multiple members of staff, providing cover in the event of absence It is best practice to acknowledge receipt of an email within 24 hours Emails are classed as records and should be retained for the appropriate period of time Where possible, a copy of the email should be Stored in the patient or service user'$ record If this is not possible, then an entry should be written into the patient Or service user s notes detailing the important content of the email and subsequent actions (for example, blood test dated 24.6.14; results emailed to patient 25.6.14; patient replied for outpatient appointment; booked for 1.7.14 at 14:30). This covers the interaction with the patient, and the original emails can be found in the email archive / system if required. Further information is available at Www englandnhs uklourworklaccessibleinfol: As the communication of, and upon, test results was an important aspect of this case, you might also be interested to know the standards the GMC sets for good patient care apply to all aspects of a doctor'$ decision-making, including their handling of test results and how communicate with and support their patients As well as the standards highlighted above; the following passages have relevance here: asking_ acting they

Providing a standard of clinical care (paragraph 15) Ensuring continuity and effective; safe handover of care (paragraph 44) Establishing partnership and good communication with patients (paragraph
49) Supporting patients to self-care including providing information and answering questions (paragraph 51) Consistent with these standards, it is expected that the doctor who orders tests as part of a patient' S care takes responsibility for following up on the test results and ensures that the results are communicated to the patient in timely way that meets their need for reassurance and support, We also expect doctors to be aware and follow clinical guidelines and other standards of good practice that relate to their particular area of work (Good Medical Practice paragraphs 1-12) Additionally, in relation to ordering following up .on and informing patients about test results, there is specific guidance from NHS England, the British Medical Association (BMA) and the Royal College of Pathology, all of which address the concerns raised in this case; In March 2016, NHS England published a set of standards for the communication of patient diagnostic test results when are discharged from hospital, available at WWW bmaorg ukladvicelemployment/gp-practiceslservice-provision/duty-of-care-to patients-regarding-test-results The standards describe acceptable, safe practice around how diagnostic test results should be communicated between secondary, primary and social care and also with patients. The intention is to ensure that hospitals take responsibility for their own tests, and this is specified in the first principle, which states the clinician who orders the test is responsible for reviewing, acting and communicating the result and actions taken to the General Practitioner and patient even if the patient has been discharged. The BMA published advice in December 2016 on the duty of_care for communicating test_results which supports the NHS England standards, and related advice published by the former National Patient Agency. The Royal College of Pathology published guidance on ' The communication 0 critical and unexpected pathology results' (October 2017) which makes clear that: Pathology providers have a responsibility to put mechanisms in place that allow the identification and rapid communication of critical and unexpected laboratory test results, It would also be expected that pathology providers negotiate with secondary care clinicians, GPs, other members of the clinical team and out-of-hours primary care providers to ensure robust mechanisms are in place so that appropriate action Is good _ they key Safety

Department of Health taken following_ communication of such results. There is also a responsibility placed upon the users of the service to ensure clear requesting instructions, contact information and awareness of self-checking %f results once requested, in an appropriate and timely manner: It is also vital that local guidelines are in place, especially in primary care; to deal with patients with critical results: It is essential that the NHS learns lessons where have gone wrong to ensure it provides safe, high quality care My officials have made enquiries with the Barts Health NHS Trust; through NHS Improvement, and [ understand that the cardiomyopathy service has taken steps to ensure that email communication with patients is included in the patient's health record. More widely, Iam advised the Trust is working to draw up guidelines on the responsibilities of clinicians in relation to email communication with patients. The Barts Health NHS Trust will respond to your report separately and so I will not include here the detail of the action the Trust has taken in relation to this case. However; I am assured that the Trust conducted a serious incident investigation into Mr Chapman'$ death and that recommendations from that report are taken forward to improve practice. I hope this information is helpful and provides assurance that there is guidance available to clinicians in this area, Where there are concerns about the conduct of an individual clinician, these should be brought to the attention of the GMC as regulator: Thank you for bringing the circumstances of Mr Chapman's death to our attention: 0^ CAROLINE DINENAGE rapid things being

Dear Dr Morris RE: Regulation 28 Reports to Prevent Future Deaths followlng the inquest touching the death of Harold Chapman (Date of Death 14.06.2016) write in response to two letters dated December 2016 received from your clerk John Thompson in relation to this matter would like to highlight the fact that these letters were addressed to Mrs G Raikes who is the Chief Executive of the Royal Brompton and Harefield Hospitals charity and not the NHS Hospltal Foundation Trust Hence there was a delay of some 2 weeks before the Regulation 28 Reports were recelved by relevant staff in the Trust: An acknowledgment of receipt was sent by email on 02.01.18. note two separate Regulatlon 28 Reports were sent following the inquest touching the death of Harold Chapman: the first addressed to Brompton NHS Trust only and the second to the Secretary of State for Health; Barts Health NHS Trust and Brompton NHS Trust; These documents have been carefully reviewed ad now set out my response below: Flrstly, should state that Mr Chapman was at no time patient under the care and treatment of the Royal Brompton and Harefield NHS Foundation Trust (RBHT) and unfortunately RBHT had no opportunity to participate in the inquest or provlde information which may have been of assistance in this matter. note that moved from Bart's Health to RBHT as a consultant cardiologist In December 2015, 6 months prior toM Chapman $ death: Our Medical Director and Responsible Officer, Dr Richard Grocott-Mason has discussed with this matter and the concerns ralsed by vou at inquest: am keen to ensure that there are systems in place at RBHT to minimise the risk of a similar sequence of events happening here The concerns vou have raised have been considered speclfically by the inherited cardiac conditions care group, the electrophysiology care group and the wider heart division and Trust and my responses are set out below. The consultantresponsible for Mr Chapman's care in Augustand November 2015 wasbased atthe timeat Barts NHS Trust andis now emplovedet the BromptonThe consultant was responsible for reviewingthe ivestigations thathe land other members othis team In their absenceLhadtequested There appearedte be_no_check mechanisms_In place toensure _that this was dong and appropriate action taken In line with the Guidelines: www rbht nhs uk @RBandh 19th

The RBHT Sudden Cardiac Death (SCD} Service is reviewing compliance with the European Society of Cardiology (ESC) 2014 guidelines on diagnosis and management of hypertrophic cardiomyopathy: The RBHT Cardiomyopathy service (which includes SCD patients) is consultant delivered with a specialist consultant present in every clinic, Clinic letters have @ standardised format including risk stratification for SCD risk (calculated using the SCD calculator) which Includes regular Holter rhythm monitoring aS per the ESC 2014 guidelines. All Holter tapes are reported by trained cardiac physiology techniclans and findings of concern communicated directly to the referring consultant by phone or email (even if requested by a fellow). Holter monitor reports are uploaded into the electronic patient record (EPR) along with all other investigation results. Abnormal Holter results are regularly discussed at MDT meetings. MDT discussion is not & pre- requisite for ICD implant at RBHT and urgent cases are referred directly to an implanting consultant who will list the patient as appropriate, Where MDT discussion is required (complex patients or those not meeting all criteria) this occurs within 2 weeks The non-urgent waiting time for ICD implant from time of agreement to implant Is of the order of 8-12 weeks. As a result of the PFD notice the inherited cardiac conditions care group are developing a standard operating procedure for notlfication of potentially significant arrhythmios, There was also a concern _in respect ofthe_Holter interpretations and the presence or_otherwise ofNSVI on_the_tracesBarts_NHS Irust have instigated a new Introduction and training regime for Its specialist slinicalfellows in the interpretation of Holter readings_ At RBHT all Holter monitor traces are Interpreted and reported by trained electrophysiology technicians Training for cardiomyopathy subspecialty fellows in Holter monitor Interpretation is provided at regular MDT meetings and consultant supervised clinics, in addition to standard training for general cardiology trainees in rhythm interpretation During_the_course of_the_inquest_the evidence_revealed_during_his dealings with Barts NHS Trust_and more speclically_thelead consultants emails were passed by Mr Chapman to the consultants It became slear_during the_Inquest that those emalls Were often not vlewed and or acted upon and a5 @ resultng response_was received by the_patlent_It Is fully appreciated that consultants are with their clinical responsibilities_covering_wards_cllnics_and on-call However_If_contact detalls are provited for_"dlredt access' to Individual doctors/consultants It_seems ebligatory that those should be viewed acknowledged patients_responded toPatient contact_with medical _professionals not just_hospital related,_is & important part_of_medical practiceWhlle_this Is @ huge task would_seem_possible_to come_upwith either_nationalor local guidelines In respect of the_ use of allforms of communication between patients andthelr_clinician (covering phone and emails) RBHT is in the process of exploring current practice in relation to email correspondence between clinicians and patients and, pending production of any national guidelines from the Department of Health, will consider production of local guidance to clinicians based on the NHS England Accessible Information Standard 'Using email and text messaging for communicating wlth patlents- guidance from the Information Governance team at NHS England' (May 2016). vou are reassured by my response to the concerns Vou have raised in relation to Mr Chapman's very sad death, the circumstances of which have been discussed at length &d the implications for the service at RBHT acknowledged