Dear Mr Haigh

Re: Gwillym Emrys PRICE

Thank you for your letter of the 13th July 2020 providing a copy of your Regulation 28 report. Accordingly, please find below the response to this report as requested:

Practice response  Mr Price was seen at the practice by a GP on the 19th February 2020. At 16:18 the GP had a long chat to the patient and the patient was provided with the Crisis team number if needed. The patient agreed to be referred to the Mental Health team as an amber case to be seen within 3 days. The patient was happy with the plan and advised that we would review him as required.  A referral to the Mental Health Team, Midlands Partnership Foundation Trust was completed on the 19th February 2020 by the GP stating that assessment was needed within 3 days.  The medical secretary at the practice contacted Midlands Partnership Foundation Trust’s Mental Health Team on the 20th February 2020 by telephone to confirm that the referral had been received, confirmation of receipt was confirmed and the team advised that the patient would be triaged on the same day.  The practice received notification from the Mental Health Team by copy of letter to patient showing that a telephone conversation / assessment had taken place with Mr Price on the 20th February and that a face to face assessment appointment had been organised for the 13th March 2020  The practice had no further contact with the patient prior to his death.

Update from Data Quality Specialist (DQS)  The practice clinical system has been checked as well as the patient’s referrals prior to death
– the Midlands Partnership Foundation Trust form used was: RF580 CMHT MH Referral Stafford 200418. The referral made on the 19th February 2020 from Gnosall Surgery at that time was the latest referral form on their clinical system.  The Midlands Partnership Foundation Trust referral form has not been updated since 2018, but it is the latest version made available.  Data Quality Specialist team confirmed that they had not received an updated version of the Midlands Partnership Foundation Trust referral form to upload onto the clinical systems. If the referral form had been emailed out to practices directly some practices might have converted the form themselves onto the system.

2

Update from
- Service Manager (Mental Health) at Midlands Partnership Foundation Trust  The single point of access team confirmed that the patient’s referral had been received. The referral form received from Gnosall Surgery was on the old referral form however the single point of access still processed the referral form and informed the practice that the wrong referral form had been used.  The referral was not rejected on the basis it was on the incorrect referral form.  Midlands Partnership Foundation Trust confirmed that some GP practices are using the correct referral form while others continue to use the old version.  The new referral form was shared with GP practices via email from the single point of access team.

Conclusion  The GP practice referred the patient and ensured the referral was received and actioned by Midlands Partnership Foundation Trust in a timely manner.  The GP practice was not aware that the wrong referral form had been used.  Midlands Partnership Foundation Trust had emailed the new version of the referral form out to practices. They were not aware of a process for updating referral forms.

Action Responsible Due Date Action Complete
1. Clinical Commissioning Group (CCG) to link Midlands Partnership Foundation Team and the DQS Team to ensure the most up to date referral form is uploaded onto the practice clinical systems.

28/08/2020 Complete
2. Midlands Partnership Foundation Trust to provide the updated referral form to the DQS Team.

03/09/2020 Complete
3. DQS Team to upload the correct Midlands Partnership Foundation Trust referral form onto all GP Practice clinical systems and ensure any previous versions are removed.

09/09/2020

4. DQS to confirm to the CCGs that the correct referral form is now available to all GP Practices and that the old referral form has been removed.

09/09/2020

5. The CCGs Quality Team to discuss information sharing processes with Midlands Partnership Foundation Trust and ask if they had put an entry of the incorrect referral form onto their DATIX system.

09/09/2020

6. The CCGs Primary Care Team to send communications out to all GP Practices highlighting the need for practices to report any notification of incorrect referral forms through the CCGs DATIX process.

09/09/2020

3

Action Responsible Due Date Action Complete
7. CCGs and DQS Team to produce a Standard Operating Procedure (SOP) for removing old referral forms and managing updated versions. This will be emailed out to all GP Practices.

09/09/2020

8. The CCGs to develop a robust process within Primary Care, Commissioning and the DQS Team to ensure referral forms are managed, updated appropriately and approved through governance processes.

30/09/2020

10. The Primary Care Team to produce a SOP for dealing with Coroner Regulation28 responses.

16/09/2020

Should you have any further queries regarding this report please do not hesitate to contact us.