Stephen Stringer
PFD Report
All Responded
Ref: 2024-0555
All 2 responses received
· Deadline: 10 Dec 2024
Coroner's Concerns (AI summary)
A GP practice's electronic enquiry system critically failed to log patient information for GP review. Additionally, a persistent hoarse voice was not widely recognized as a laryngeal cancer red flag by healthcare professionals or the public.
View full coroner's concerns
1. The inquest heard evidence that the GP practice had in accordance with the local requirements introduced an electronic patient enquiry service alongside a telephone service. Patients contacting the surgery had to select which stream within the practice their enquiry went to. It was not always clear from the headings whether the query would be seen by a GP or the admin team. Information that went into the admin work stream from a patient did not go onto the patient record and was not seen by a doctor. The GPs at the practice were unaware of this and patients had no way of knowing that the information they had sent in was not in the patient record. The practice involved in this inquest had taken steps since identifying the issue to mitigate the risks. However the evidence before the inquest was that the software in question was widely used by GP practices within Derbyshire and nationally.
2. The evidence from the ENT consultant was that it was important that where a patient presented with a hoarse voice that all health professionals explored for how long it had been an issue and whether there was a realistic treatable cause for it .In the absence of any clear cause such as a throat infection or where there was no clear response to treatment then a hoarse voice should be seen as a red flag symptom for laryngeal cancers and result in a referral on the 2 week wait. It was clear from the evidence at the inquest that unlike other cancer red flags such as blood in urine the significance of a persistent hoarse voice was not recognised by a number of different healthcare professionals who saw him. The inquest was told that early detection of laryngeal cancers through early referrals on the 2 week wait significantly improves the outcomes for patients because far more treatment options are open to clinicians.
3. A number of different health professionals had input into his care. This meant that there was no one health professional who had a good insight into his overall deterioration and symptoms. Where multiple practitioners were involved one person needed to maintain oversight or the electronic patient record needed to have easily accessible clear action plans and notes were required so that a patient and their symptoms could be seen holistically rather than a one off.
4. There was also evidence that there is limited public awareness of how significant a change in voice can be and recognising it as a potential cancer symptom. Greater public awareness of symptoms of laryngeal cancers would ensure the public were better placed to seek help at an early stage.
2. The evidence from the ENT consultant was that it was important that where a patient presented with a hoarse voice that all health professionals explored for how long it had been an issue and whether there was a realistic treatable cause for it .In the absence of any clear cause such as a throat infection or where there was no clear response to treatment then a hoarse voice should be seen as a red flag symptom for laryngeal cancers and result in a referral on the 2 week wait. It was clear from the evidence at the inquest that unlike other cancer red flags such as blood in urine the significance of a persistent hoarse voice was not recognised by a number of different healthcare professionals who saw him. The inquest was told that early detection of laryngeal cancers through early referrals on the 2 week wait significantly improves the outcomes for patients because far more treatment options are open to clinicians.
3. A number of different health professionals had input into his care. This meant that there was no one health professional who had a good insight into his overall deterioration and symptoms. Where multiple practitioners were involved one person needed to maintain oversight or the electronic patient record needed to have easily accessible clear action plans and notes were required so that a patient and their symptoms could be seen holistically rather than a one off.
4. There was also evidence that there is limited public awareness of how significant a change in voice can be and recognising it as a potential cancer symptom. Greater public awareness of symptoms of laryngeal cancers would ensure the public were better placed to seek help at an early stage.
Responses
Action Planned
The DHSC highlights NHS initiatives to improve patient access and awareness of head and neck cancer symptoms. The NHS England Safety Team have contacted Derby and Derbyshire Integrated Care Board to understand the clinical safety assurance processes in place and have offered to support future safety training within the ICB and GP community if required. (AI summary)
The DHSC highlights NHS initiatives to improve patient access and awareness of head and neck cancer symptoms. The NHS England Safety Team have contacted Derby and Derbyshire Integrated Care Board to understand the clinical safety assurance processes in place and have offered to support future safety training within the ICB and GP community if required. (AI summary)
View full response
Dear Ms Mutch
Thank you for the Regulation 28 report of 15th October sent to the Department of Health and Social Care about the death of Mr Stephen Charles Stringer. I am replying as the Minister of State for Care, responsible for primary care and general practice.
Firstly, I would like to say how saddened I was to read of the circumstances of Mr Stringer’s death and I offer my sincere condolences to his family and loved ones. The circumstances your report describes are concerning and I am grateful to you for bringing these matters to my attention. The department and practices must be cognizant to the recent changes made to modernise telephone systems, include call routing, and understand that these may not be as clear as they need to be for all patients. This is unacceptable and it must be very clear to all patients what steps are required to access care when they contact their practice.
Call routing enables patients to choose options via their keypad or voice options to enable direct routing to the right person or team. When properly configured, these systems can divert some demand away from phones at busy times, making it easier to get through to someone to book an appointment. However, it is crucial that all triage and appointment systems ensure patients are correctly routed - and if mistakes occur, that these are promptly rectified to connect patients with the right team or person. We want to make sure that patients are able to easily access primary care, and this is not a complex system, we need to do better, so patients can receive the care they deserve. It is deeply upsetting that Mr Stringer was not able to easily access his general practice and his health tragically suffered due to this.
General practices are independent businesses who are contracted by NHS commissioners to perform medical services, and it is the responsibility of the individual practice (provider) to have reliable systems in place to manage interactions with patients. It is essential that clinical issues mistakenly categorized as administrative are identified and appropriately A10
managed by care navigators. If a practice is unable to effectively monitor its systems to identify and address clinical concerns, a system should be in place to manage this. We recognise that practices require adequate support to be able to manage these systems. NHS England produced guidance on thishttps://www.england.nhs.uk/long-read/how-to- improve-care-navigation-in-general-practice/ in May 2024. The guidance provides key rules to help guide practices on their role in care navigation. Firstly, clinical requests not allocated by a care navigator (directly over the phone) need to come into a single flow for assessment and all administrative requests must have a clear distribution route within practice and agreed turnaround times. Practices are responsible for tailoring the exact operations and timeframes of this to their own requirements and patient cohorts. Additionally, the Digital Clinical Strategy published in 2021 outlines NHS England’s responsibility and commitment to improve the safety of digital technologies in health and care now and in the future, as well as identifying and promoting the use of digital technologies as solutions to patient safety challenges. The Clinical Safety Standards DCB0129 and DCB 0160 provide the legal framework and best practice to help organisations manage and mitigate risks associated with development and use. NHS England are responsible for ensuring that the Clinical Safety Standards continue to influence safety, and a comprehensive review of both standards is underway and due to complete in 2025 which will involve wide stakeholder engagement. Patients that are able to see the same practitioner benefit from better health outcomes. We expect that practitioners who have had prior contact with a patient, would recognise the importance of continuity of care and proactively offer this option whenever possible. It is unacceptable that patients that present with red flag symptoms are consistently missed and misdiagnosed. NICE’s NG12 guidance: Overview | Suspected cancer: recognition and referral | Guidance | NICE provides guidance to practitioners on urgent suspected cancer referrals, which clearly identifies ‘persistent unexplained hoarseness’ as requiring urgent referral. We would expect healthcare professionals to be aware of this guidance, which is of long standing. A number of national charities highlight a hoarse voice as a potential sign of cancer on their websites (laryngeal or lung cancer being the most common types with this symptom) and there have been a number of local campaigns on this as well. More recently, NHSE has partnered with ASDA to put warnings on mouthcare products such as toothpaste and mouthwash to highlight the possible early signs on head and neck cancer, including hoarseness.
mouth-cancer-symptoms-on-toothpaste-and-mouthwash/ We understand that NHS General Practices need to be responsive to the needs of their patients. Following contact made by a patient the practice must manage the presenting complaint in a safe and timely way in line with the Health and Social Care Act 2008 Regulations 2014: Regulation 12 Safe care and treatment. The intention of this regulation is to prevent people from receiving unsafe care and treatment and prevent avoidable harm or A11
risk of harm. CQC would also expect those working within a service to have the knowledge and skills to use the systems in place, and for there to be sufficient numbers of staff with the right skills employed to meet the needs of those using the service. This is also in accordance with Regulation 12 and Regulation 18: Staffing. Regulation 9 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2008 requires providers to provide patients with information about their care and treatment options. CQC would expect this to include information on how to access care and treatment. Regulation 17 Good governance requires the provider to ensure they have systems and processes in place to ensure compliance with other requirements of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, including those referenced here. Additional information was received alongside the coroner’s report that has been shared with the Derbyshire ICB. The NHS England Safety Team have been in contact with Derby and Derbyshire Integrated Care Board to understand the clinical safety assurance processes in place and have offered to support future safety training within the ICB and GP community if required.
Thank you for the Regulation 28 report of 15th October sent to the Department of Health and Social Care about the death of Mr Stephen Charles Stringer. I am replying as the Minister of State for Care, responsible for primary care and general practice.
Firstly, I would like to say how saddened I was to read of the circumstances of Mr Stringer’s death and I offer my sincere condolences to his family and loved ones. The circumstances your report describes are concerning and I am grateful to you for bringing these matters to my attention. The department and practices must be cognizant to the recent changes made to modernise telephone systems, include call routing, and understand that these may not be as clear as they need to be for all patients. This is unacceptable and it must be very clear to all patients what steps are required to access care when they contact their practice.
Call routing enables patients to choose options via their keypad or voice options to enable direct routing to the right person or team. When properly configured, these systems can divert some demand away from phones at busy times, making it easier to get through to someone to book an appointment. However, it is crucial that all triage and appointment systems ensure patients are correctly routed - and if mistakes occur, that these are promptly rectified to connect patients with the right team or person. We want to make sure that patients are able to easily access primary care, and this is not a complex system, we need to do better, so patients can receive the care they deserve. It is deeply upsetting that Mr Stringer was not able to easily access his general practice and his health tragically suffered due to this.
General practices are independent businesses who are contracted by NHS commissioners to perform medical services, and it is the responsibility of the individual practice (provider) to have reliable systems in place to manage interactions with patients. It is essential that clinical issues mistakenly categorized as administrative are identified and appropriately A10
managed by care navigators. If a practice is unable to effectively monitor its systems to identify and address clinical concerns, a system should be in place to manage this. We recognise that practices require adequate support to be able to manage these systems. NHS England produced guidance on thishttps://www.england.nhs.uk/long-read/how-to- improve-care-navigation-in-general-practice/ in May 2024. The guidance provides key rules to help guide practices on their role in care navigation. Firstly, clinical requests not allocated by a care navigator (directly over the phone) need to come into a single flow for assessment and all administrative requests must have a clear distribution route within practice and agreed turnaround times. Practices are responsible for tailoring the exact operations and timeframes of this to their own requirements and patient cohorts. Additionally, the Digital Clinical Strategy published in 2021 outlines NHS England’s responsibility and commitment to improve the safety of digital technologies in health and care now and in the future, as well as identifying and promoting the use of digital technologies as solutions to patient safety challenges. The Clinical Safety Standards DCB0129 and DCB 0160 provide the legal framework and best practice to help organisations manage and mitigate risks associated with development and use. NHS England are responsible for ensuring that the Clinical Safety Standards continue to influence safety, and a comprehensive review of both standards is underway and due to complete in 2025 which will involve wide stakeholder engagement. Patients that are able to see the same practitioner benefit from better health outcomes. We expect that practitioners who have had prior contact with a patient, would recognise the importance of continuity of care and proactively offer this option whenever possible. It is unacceptable that patients that present with red flag symptoms are consistently missed and misdiagnosed. NICE’s NG12 guidance: Overview | Suspected cancer: recognition and referral | Guidance | NICE provides guidance to practitioners on urgent suspected cancer referrals, which clearly identifies ‘persistent unexplained hoarseness’ as requiring urgent referral. We would expect healthcare professionals to be aware of this guidance, which is of long standing. A number of national charities highlight a hoarse voice as a potential sign of cancer on their websites (laryngeal or lung cancer being the most common types with this symptom) and there have been a number of local campaigns on this as well. More recently, NHSE has partnered with ASDA to put warnings on mouthcare products such as toothpaste and mouthwash to highlight the possible early signs on head and neck cancer, including hoarseness.
mouth-cancer-symptoms-on-toothpaste-and-mouthwash/ We understand that NHS General Practices need to be responsive to the needs of their patients. Following contact made by a patient the practice must manage the presenting complaint in a safe and timely way in line with the Health and Social Care Act 2008 Regulations 2014: Regulation 12 Safe care and treatment. The intention of this regulation is to prevent people from receiving unsafe care and treatment and prevent avoidable harm or A11
risk of harm. CQC would also expect those working within a service to have the knowledge and skills to use the systems in place, and for there to be sufficient numbers of staff with the right skills employed to meet the needs of those using the service. This is also in accordance with Regulation 12 and Regulation 18: Staffing. Regulation 9 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2008 requires providers to provide patients with information about their care and treatment options. CQC would expect this to include information on how to access care and treatment. Regulation 17 Good governance requires the provider to ensure they have systems and processes in place to ensure compliance with other requirements of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, including those referenced here. Additional information was received alongside the coroner’s report that has been shared with the Derbyshire ICB. The NHS England Safety Team have been in contact with Derby and Derbyshire Integrated Care Board to understand the clinical safety assurance processes in place and have offered to support future safety training within the ICB and GP community if required.
Action Planned
The ICB outlines planned actions, including verbally updating PCN Cancer Leads about a webinar, inviting a consultant for an educational slot, including educational information in the Primary Care Bulletin and LMC newsletter, developing public-facing communications, and working with HUB+ to include record-keeping support. (AI summary)
The ICB outlines planned actions, including verbally updating PCN Cancer Leads about a webinar, inviting a consultant for an educational slot, including educational information in the Primary Care Bulletin and LMC newsletter, developing public-facing communications, and working with HUB+ to include record-keeping support. (AI summary)
View full response
Regulation 28 Report to Prevent Future Deaths Derby and Derbyshire Integrated Care Board Response Derby and Derbyshire Integrated Care Board (DDICB) would like to extend our sympathies to the family of Mr Stringer. Please find below the ICBs response and future plans in regard to the Regulation 28 Report to Prevent Future Deaths. If there are any areas which you feel you would like more information or to discuss in person this will be arranged. On 8th April 2024 the coroner commenced an investigation into the death of Mr S C Stringer. The investigation concluded on the 25th of September 2024, and the conclusion was: Mr Stringer died from squamous cell carcinoma of the glottis where the significance of his symptoms including a prolonged period of hoarse voice was not appreciated until the cancer had progressed to Stage4 The medical cause of death was 1a Squamous cell carcinoma of the glottis; II Asbestos-related interstitial lung disease, Ischaemic heart disease. The following report and action plan is in response to the matters of concern revealed through the course of the inquest as below. Each of these areas has been reviewed separately with actions to prevent future deaths captured in the action plan at the end of the report. This will be reviewed as per the timescales included within the report.
1. The inquest heard evidence that the GP practice had in accordance with the local requirements introduced an electronic patient enquiry service alongside a telephone service. Patients contacting the surgery had to select which stream within the practice their enquiry went to. It was not always clear from the headings whether the query would be seen by a GP or the admin team. Information that went into the admin work stream from a patient did not go onto the patient record and was not seen by a doctor. The GPs at the practice were unaware of this and patients had no way of knowing that the information they had sent in was not in the patient record. The practice involved in this inquest had taken steps since identifying the issue to mitigate the risks. However, the evidence before the inquest was that the software in question was widely used by GP practices within Derbyshire and nationally.
2. The evidence from the ENT consultant was that it was important that where a patient presented with a hoarse voice that all health professionals explored for how long it had been an issue and whether there was a realistic treatable cause for it. In the absence of any clear cause such as a throat infection or where there was no clear response to treatment then a hoarse voice should be seen as a red flag symptom for laryngeal cancers and result in a referral on the 2 weeks wait. It was clear from the evidence at the inquest that unlike other cancer red flags such as blood in urine the significance of a persistent hoarse voice was not recognised by a number of different healthcare professionals who saw him. The inquest was told that early detection of laryngeal cancers through early referrals on the 2 weeks wait significantly improves the outcomes for patients because far more treatment options are open to clinicians.
3. A number of different health professionals had input into his care. This meant that there was no one health professional who had a good insight into his overall deterioration and symptoms. Where multiple practitioners were involved one person needed to maintain A1
oversight or the electronic patient record needed to have easily accessible clear action plans and notes were required so that a patient and their symptoms could be seen holistically rather than a one off.
4. There was also evidence that there is limited public awareness of how significant a change in voice can be and recognising it as a potential cancer symptom. Greater public awareness of symptoms of laryngeal cancers would ensure the public were better placed to seek help at an early stage.
1. The inquest heard evidence that the GP practice had in accordance with the local requirements introduced an electronic patient enquiry service alongside a telephone service. Patients contacting the surgery had to select which stream within the practice their enquiry went to. It was not always clear from the headings whether the query would be seen by a GP or the admin team. Information that went into the admin work stream from a patient did not go onto the patient record and was not seen by a doctor. The GPs at the practice were unaware of this and patients had no way of knowing that the information they had sent in was not in the patient record. The practice involved in this inquest had taken steps since identifying the issue to mitigate the risks. However, the evidence before the inquest was that the software in question was widely used by GP practices within Derbyshire and nationally. Nationally guidance issued by NHS England (NHS England » New digital and online services requirements: guidance for GP practices) from October 2021, Practices were contractually required to "offer and promote" several digital services to their patients which included:
• An online consultation tools.
• A video consultation tool.
• A secure electronic communication method.
• An online facility to provide and update personal or contact information. Online consultation tools were first implemented across Derbyshire for a small number of practices in 2018 utilising national ETTF funding. North of England Commissioning Support Unit (NECS) Projects were commissioned to undergo market research to identify potential suppliers, which met the ETTF criteria for digital patient-initiated requests into practices. A shortlist of suppliers/tools were presented to early adopter practices who choose and implemented an online consultation tool to pilot based on their local needs. Demand and uptake of online consultation tools significantly increased in 2020 as part of the Covid-19 response with tools either being offered 'free' to GP Practices by providers or ultimately then rolled into national contracts. During this time practices were encouraged to implement online consultation tools from national teams to support remote clinical care.
While the ICB is currently the contract holder for online consultation tools in use within Primary Care, the choice of which online consultation to utilise resides with the GP Practice. Currently, all GP Practices within Derby and Derbyshire have access to at least one online consultation tool, but there is some duplication with some practices having access to two, depending upon local need. A2
Support for GP Practices is provided directly by the systems supplier who typically offer initial onboarding sessions to GP Practices to enable them to understand the capabilities of their tool along with regular workshops, demonstrations, and other online support. There are also online communities, Frequently Asked Questions, and resources to support GP Practices. The online consultation tools are delivered nationally and at scale with the support of the National Procurement Hub and frameworks, with little or no capability to vary the layout, contents, etc on a local basis. There is a wide range of functionality available across the online consultation solutions we have within our system ranging from simple forms, through to more complex systems which aim to direct the patient to self-care. Across Derby and Derbyshire Integrated Care Board (DDICB) geography these systems began being implemented in 2018. The ICB has never mandated GP Practices to use any online tools and have always been guided by the GP Practices; in the early pandemic, we had tools such as AccuRx who made their tools available to GP Practices in a way that didn't need the ICB or North of England Commissioning Support Unit (NECS) to approve or install and hence we saw an explosion of use of these systems. These were either provided for free or through a national agreement (through NHS England) – the ICB took on responsibility for managing the contract and finding the funding once these national funding agreements ceased. The ICB holds contracts for online consultation and other tools that we have been asked to contract. For these tools the ICB has engaged with a general practice clinician with an interest in digital safety to review clinical Digital Safety on an Ad Hoc basis and have previously commissioned a Clinical Safety Assurance service from NECS. In partnership with the Digital Clinical Patient Safety Officer and Head of Digital and Information Governance the DDICB will develop a clinical safety service around future triage and online procurements as a standard rather than on an Ad Hoc basis. Until this is established the ICB will engage with general practice clinician to provide this service. The DDICB holds quarterly Clinical Governance Leads meetings with general practice – a GP or experienced clinician attends from each general practice, the requirements for Digital Clinical Patient Safety will be discussed as part of overall learning, the Digital Clinical Safety Team at NHSE have also offered to support this session. Prior to this the DDICB will raise awareness of the importance of digital clinical safety across general practice through inclusion of available training in the DDICB weekly General Practice bulletin and direct email communication to both General Practice and Primary Care Networks. The DDICB will discuss with the Derby and Derbyshire Local Medical Council and request information also be included within their weekly bulletin. The DDICB will engage with the Derby and Derbyshire General Practice Provider Board as a further opportunity to raise Digital Clinical Patient Safety in relation to existing tools and those products procured in the future via the ICB or directly from general practice.
2. The evidence from the ENT consultant was that it was important that where a patient presented with a hoarse voice that all health professionals explored for how long it had been an issue and whether there was a realistic treatable cause for it. In the absence of any clear cause such as a throat infection or where there was no clear response to treatment then a hoarse A3
voice should be seen as a red flag symptom for laryngeal cancers and result in a referral on the 2 weeks wait. It was clear from the evidence at the inquest that unlike other cancer red flags such as blood in urine the significance of a persistent hoarse voice was not recognised by a number of different healthcare professionals who saw him. The inquest was told that early detection of laryngeal cancers through early referrals on the 2 weeks wait significantly improves the outcomes for patients because far more treatment options are open to clinicians. The DDICB Clinical Lead for Cancer and Senior Commissioning Manager Cancer will. Promote the GatewayC module for Head and Neck (education Package) through the following channels.
• PCN Cancer Leads
• Primary Care bulletin
• The Hub plus route
• LMC Record a webinar with Head & Neck Consultants and the DDICB Clinical Lead in a Q&A style to share across primary care around signs & symptoms. Raise awareness at the next PCN Cancer Leads meeting. Work with Communications to develop some public facing comms around recognising signs and symptoms. To access the GatewayC training GPs can register for a free account and watch live webinars, recordings or do online modules, which can provide CPD evidence. This is not mandated but includes lots of useful training around different cancer tumour sites. The team will promote this education and webinar through the routes above and share the learning from this report. Please find below a summary of the Gateway C training for your review. Head and Neck - Early Diagnosis - Sum
3. A number of different health professionals had input into his care. This meant that there was no one health professional who had a good insight into his overall deterioration and symptoms. Where multiple practitioners were involved one person needed to maintain oversight or the electronic patient record needed to have easily accessible clear action plans and notes were required so that a patient and their symptoms could be seen holistically rather than a one off. It is now becoming the normal for a patient to not see the same GP during a course of an illness or when seeking care and management for an illness, this makes accurate consultation records even more important. The electronic patient record now acts as the continuity of information with regards to patients supporting direct patient care. At the Clinical Governance Leads meeting with general practice the below documents will be discussed as part of the Patient safety standard agenda item. NHS England » High quality patient records A4
Good medical practice 2024 - GMC The DDICB will also liaise with HUB+ to discuss the possibility of Record Keeping being added to their suite of online information and support for general practice. The DDICB recognises the importance of maintaining accurate electronic patient records and ensures digital solutions procured can integrate with both SystmOne and EMIS. Automated integration is recommended to practices during onboarding and during upgrades, however practices may opt out of this feature, choosing to manually extract and upload requests and interactions.
4. There was also evidence that there is limited public awareness of how significant a change in voice can be and recognising it as a potential cancer symptom. Greater public awareness of symptoms of laryngeal cancers would ensure the public were better placed to seek help at an early stage. There isn't a national campaign covering his type of cancer so the DDICB will create our own messaging. To develop this the DDICB Communications Team will work with the Primary Care Quality and Cancer Commissioning Teams. This will then be included in the following internal and public facing information.
• Items in the Primary Care bulletin
• Items in staff and stakeholder bulletins
• Item in the Joined Up Care Derbyshire newsletter
• News article
• Social media
• Circulate communications to our system stakeholders to include in their comms channels (including community groups) A5
Action Plan Action Number Overview of DDICB actions Action Owner Action Updates Proposed Completion date Digital clinical patient safety. 1 a Digital Clinical Patient Safety Officer and Head of Digital and Information Governance the DDICB will develop a clinical safety service around future triage and online procurements as a standard.
Head of Digital and Information Governance
01.05.2025 1b Discussion and presentation at Clinical Governance Leads meeting. Asst Director Nursing &Quality Primary Care
01.05.2025 1c DDICB will raise awareness of the requirements of digital clinical safety across general practice through inclusion of available training and information in the DDICB weekly General Practice bulletin and direct email communication to both General Practice and Primary Care Networks. Asst Director N&Q PC Head of Digital and Information Governance
01.02.2025 1d The DDICB will discuss with the Derby and Derbyshire Local Medical Council and request information also be included within their weekly bulletin. Asst Director N&Q PC
01.02.2025 1e The DDICB will engage with the Derby and Derbyshire General Practice Provider Board as a further opportunity to raise Digital Clinical Patient Safety in relation to existing tools and those products procured in the future via the ICB or directly from general practice. Head of Digital and Information Governance
01.02.2025 A6
Asst Director N&Q PC Education - Head & Neck Cancer 2 a Record a webinar with Head & Neck Cancer Consultants and the DDICB Clinical Lead in a Q&A style to share across primary care around signs & symptoms. DDICB Clinical Lead for Cancer Senior Commissioning manager Cancer PCN Cancer Leads verbally updated about the webinar scheduled for 4th December at 27th Nov meeting.
01.02.2025 2b Education session for PCN Cancer Leads DDICB Clinical Lead for Cancer Senior Commissioning manager Cancer Planning to invite H&N Consultant from UHDB to either January or March meeting for an educational slot at the meeting. 2c Inclusion of educational information into the Primary Care Bulletin DDICB Clinical Lead for Cancer Senior Commissioning manager Cancer
01.02.2025 2d Link with Hub Plus (Derby and Derbyshire PC Training provider) to include links to education DDICB Clinical Lead for Cancer Senior Commissioning manager Cancer
01.02.2025 2e Inclusion of educational information into the Local Medical Council weekly newsletter DDICB Clinical Lead for Cancer Senior Commissioning A7
manager Cancer 2f Work with Communications to develop some public facing comms around recognising signs and symptoms. DDICB Clinical Lead for Cancer Senior Commissioning manager Cancer
01.01.2025 –
01.04.2025 Communications with staff, stakeholders and wider public 3a Work with the DDICB Cancer clinical lead and senior commissioning manager to re inclusion of information in the following. o Primary Care bulletin o Items in staff and stakeholder bulletins o Item in the Joined Up Care Derbyshire newsletter o News article o Social media o Circulate communications to our system stakeholders to include in their comms channels (including community groups) Campaigns Manager
01.04.2025 Record Keeping 4a The DDICB will also liaise with HUB+ to discuss the possibility of Record Keeping being added to their suite of online information and support for general practice. Asst Director N&Q PC Email sent 29.11.2024 4b At the Clinical Governance Leads meeting with general practice the below documents will be Asst Director N&Q PC
01.05.2025 A8
discussed as part of the Patient safety standard agenda item. A9
1. The inquest heard evidence that the GP practice had in accordance with the local requirements introduced an electronic patient enquiry service alongside a telephone service. Patients contacting the surgery had to select which stream within the practice their enquiry went to. It was not always clear from the headings whether the query would be seen by a GP or the admin team. Information that went into the admin work stream from a patient did not go onto the patient record and was not seen by a doctor. The GPs at the practice were unaware of this and patients had no way of knowing that the information they had sent in was not in the patient record. The practice involved in this inquest had taken steps since identifying the issue to mitigate the risks. However, the evidence before the inquest was that the software in question was widely used by GP practices within Derbyshire and nationally.
2. The evidence from the ENT consultant was that it was important that where a patient presented with a hoarse voice that all health professionals explored for how long it had been an issue and whether there was a realistic treatable cause for it. In the absence of any clear cause such as a throat infection or where there was no clear response to treatment then a hoarse voice should be seen as a red flag symptom for laryngeal cancers and result in a referral on the 2 weeks wait. It was clear from the evidence at the inquest that unlike other cancer red flags such as blood in urine the significance of a persistent hoarse voice was not recognised by a number of different healthcare professionals who saw him. The inquest was told that early detection of laryngeal cancers through early referrals on the 2 weeks wait significantly improves the outcomes for patients because far more treatment options are open to clinicians.
3. A number of different health professionals had input into his care. This meant that there was no one health professional who had a good insight into his overall deterioration and symptoms. Where multiple practitioners were involved one person needed to maintain A1
oversight or the electronic patient record needed to have easily accessible clear action plans and notes were required so that a patient and their symptoms could be seen holistically rather than a one off.
4. There was also evidence that there is limited public awareness of how significant a change in voice can be and recognising it as a potential cancer symptom. Greater public awareness of symptoms of laryngeal cancers would ensure the public were better placed to seek help at an early stage.
1. The inquest heard evidence that the GP practice had in accordance with the local requirements introduced an electronic patient enquiry service alongside a telephone service. Patients contacting the surgery had to select which stream within the practice their enquiry went to. It was not always clear from the headings whether the query would be seen by a GP or the admin team. Information that went into the admin work stream from a patient did not go onto the patient record and was not seen by a doctor. The GPs at the practice were unaware of this and patients had no way of knowing that the information they had sent in was not in the patient record. The practice involved in this inquest had taken steps since identifying the issue to mitigate the risks. However, the evidence before the inquest was that the software in question was widely used by GP practices within Derbyshire and nationally. Nationally guidance issued by NHS England (NHS England » New digital and online services requirements: guidance for GP practices) from October 2021, Practices were contractually required to "offer and promote" several digital services to their patients which included:
• An online consultation tools.
• A video consultation tool.
• A secure electronic communication method.
• An online facility to provide and update personal or contact information. Online consultation tools were first implemented across Derbyshire for a small number of practices in 2018 utilising national ETTF funding. North of England Commissioning Support Unit (NECS) Projects were commissioned to undergo market research to identify potential suppliers, which met the ETTF criteria for digital patient-initiated requests into practices. A shortlist of suppliers/tools were presented to early adopter practices who choose and implemented an online consultation tool to pilot based on their local needs. Demand and uptake of online consultation tools significantly increased in 2020 as part of the Covid-19 response with tools either being offered 'free' to GP Practices by providers or ultimately then rolled into national contracts. During this time practices were encouraged to implement online consultation tools from national teams to support remote clinical care.
While the ICB is currently the contract holder for online consultation tools in use within Primary Care, the choice of which online consultation to utilise resides with the GP Practice. Currently, all GP Practices within Derby and Derbyshire have access to at least one online consultation tool, but there is some duplication with some practices having access to two, depending upon local need. A2
Support for GP Practices is provided directly by the systems supplier who typically offer initial onboarding sessions to GP Practices to enable them to understand the capabilities of their tool along with regular workshops, demonstrations, and other online support. There are also online communities, Frequently Asked Questions, and resources to support GP Practices. The online consultation tools are delivered nationally and at scale with the support of the National Procurement Hub and frameworks, with little or no capability to vary the layout, contents, etc on a local basis. There is a wide range of functionality available across the online consultation solutions we have within our system ranging from simple forms, through to more complex systems which aim to direct the patient to self-care. Across Derby and Derbyshire Integrated Care Board (DDICB) geography these systems began being implemented in 2018. The ICB has never mandated GP Practices to use any online tools and have always been guided by the GP Practices; in the early pandemic, we had tools such as AccuRx who made their tools available to GP Practices in a way that didn't need the ICB or North of England Commissioning Support Unit (NECS) to approve or install and hence we saw an explosion of use of these systems. These were either provided for free or through a national agreement (through NHS England) – the ICB took on responsibility for managing the contract and finding the funding once these national funding agreements ceased. The ICB holds contracts for online consultation and other tools that we have been asked to contract. For these tools the ICB has engaged with a general practice clinician with an interest in digital safety to review clinical Digital Safety on an Ad Hoc basis and have previously commissioned a Clinical Safety Assurance service from NECS. In partnership with the Digital Clinical Patient Safety Officer and Head of Digital and Information Governance the DDICB will develop a clinical safety service around future triage and online procurements as a standard rather than on an Ad Hoc basis. Until this is established the ICB will engage with general practice clinician to provide this service. The DDICB holds quarterly Clinical Governance Leads meetings with general practice – a GP or experienced clinician attends from each general practice, the requirements for Digital Clinical Patient Safety will be discussed as part of overall learning, the Digital Clinical Safety Team at NHSE have also offered to support this session. Prior to this the DDICB will raise awareness of the importance of digital clinical safety across general practice through inclusion of available training in the DDICB weekly General Practice bulletin and direct email communication to both General Practice and Primary Care Networks. The DDICB will discuss with the Derby and Derbyshire Local Medical Council and request information also be included within their weekly bulletin. The DDICB will engage with the Derby and Derbyshire General Practice Provider Board as a further opportunity to raise Digital Clinical Patient Safety in relation to existing tools and those products procured in the future via the ICB or directly from general practice.
2. The evidence from the ENT consultant was that it was important that where a patient presented with a hoarse voice that all health professionals explored for how long it had been an issue and whether there was a realistic treatable cause for it. In the absence of any clear cause such as a throat infection or where there was no clear response to treatment then a hoarse A3
voice should be seen as a red flag symptom for laryngeal cancers and result in a referral on the 2 weeks wait. It was clear from the evidence at the inquest that unlike other cancer red flags such as blood in urine the significance of a persistent hoarse voice was not recognised by a number of different healthcare professionals who saw him. The inquest was told that early detection of laryngeal cancers through early referrals on the 2 weeks wait significantly improves the outcomes for patients because far more treatment options are open to clinicians. The DDICB Clinical Lead for Cancer and Senior Commissioning Manager Cancer will. Promote the GatewayC module for Head and Neck (education Package) through the following channels.
• PCN Cancer Leads
• Primary Care bulletin
• The Hub plus route
• LMC Record a webinar with Head & Neck Consultants and the DDICB Clinical Lead in a Q&A style to share across primary care around signs & symptoms. Raise awareness at the next PCN Cancer Leads meeting. Work with Communications to develop some public facing comms around recognising signs and symptoms. To access the GatewayC training GPs can register for a free account and watch live webinars, recordings or do online modules, which can provide CPD evidence. This is not mandated but includes lots of useful training around different cancer tumour sites. The team will promote this education and webinar through the routes above and share the learning from this report. Please find below a summary of the Gateway C training for your review. Head and Neck - Early Diagnosis - Sum
3. A number of different health professionals had input into his care. This meant that there was no one health professional who had a good insight into his overall deterioration and symptoms. Where multiple practitioners were involved one person needed to maintain oversight or the electronic patient record needed to have easily accessible clear action plans and notes were required so that a patient and their symptoms could be seen holistically rather than a one off. It is now becoming the normal for a patient to not see the same GP during a course of an illness or when seeking care and management for an illness, this makes accurate consultation records even more important. The electronic patient record now acts as the continuity of information with regards to patients supporting direct patient care. At the Clinical Governance Leads meeting with general practice the below documents will be discussed as part of the Patient safety standard agenda item. NHS England » High quality patient records A4
Good medical practice 2024 - GMC The DDICB will also liaise with HUB+ to discuss the possibility of Record Keeping being added to their suite of online information and support for general practice. The DDICB recognises the importance of maintaining accurate electronic patient records and ensures digital solutions procured can integrate with both SystmOne and EMIS. Automated integration is recommended to practices during onboarding and during upgrades, however practices may opt out of this feature, choosing to manually extract and upload requests and interactions.
4. There was also evidence that there is limited public awareness of how significant a change in voice can be and recognising it as a potential cancer symptom. Greater public awareness of symptoms of laryngeal cancers would ensure the public were better placed to seek help at an early stage. There isn't a national campaign covering his type of cancer so the DDICB will create our own messaging. To develop this the DDICB Communications Team will work with the Primary Care Quality and Cancer Commissioning Teams. This will then be included in the following internal and public facing information.
• Items in the Primary Care bulletin
• Items in staff and stakeholder bulletins
• Item in the Joined Up Care Derbyshire newsletter
• News article
• Social media
• Circulate communications to our system stakeholders to include in their comms channels (including community groups) A5
Action Plan Action Number Overview of DDICB actions Action Owner Action Updates Proposed Completion date Digital clinical patient safety. 1 a Digital Clinical Patient Safety Officer and Head of Digital and Information Governance the DDICB will develop a clinical safety service around future triage and online procurements as a standard.
Head of Digital and Information Governance
01.05.2025 1b Discussion and presentation at Clinical Governance Leads meeting. Asst Director Nursing &Quality Primary Care
01.05.2025 1c DDICB will raise awareness of the requirements of digital clinical safety across general practice through inclusion of available training and information in the DDICB weekly General Practice bulletin and direct email communication to both General Practice and Primary Care Networks. Asst Director N&Q PC Head of Digital and Information Governance
01.02.2025 1d The DDICB will discuss with the Derby and Derbyshire Local Medical Council and request information also be included within their weekly bulletin. Asst Director N&Q PC
01.02.2025 1e The DDICB will engage with the Derby and Derbyshire General Practice Provider Board as a further opportunity to raise Digital Clinical Patient Safety in relation to existing tools and those products procured in the future via the ICB or directly from general practice. Head of Digital and Information Governance
01.02.2025 A6
Asst Director N&Q PC Education - Head & Neck Cancer 2 a Record a webinar with Head & Neck Cancer Consultants and the DDICB Clinical Lead in a Q&A style to share across primary care around signs & symptoms. DDICB Clinical Lead for Cancer Senior Commissioning manager Cancer PCN Cancer Leads verbally updated about the webinar scheduled for 4th December at 27th Nov meeting.
01.02.2025 2b Education session for PCN Cancer Leads DDICB Clinical Lead for Cancer Senior Commissioning manager Cancer Planning to invite H&N Consultant from UHDB to either January or March meeting for an educational slot at the meeting. 2c Inclusion of educational information into the Primary Care Bulletin DDICB Clinical Lead for Cancer Senior Commissioning manager Cancer
01.02.2025 2d Link with Hub Plus (Derby and Derbyshire PC Training provider) to include links to education DDICB Clinical Lead for Cancer Senior Commissioning manager Cancer
01.02.2025 2e Inclusion of educational information into the Local Medical Council weekly newsletter DDICB Clinical Lead for Cancer Senior Commissioning A7
manager Cancer 2f Work with Communications to develop some public facing comms around recognising signs and symptoms. DDICB Clinical Lead for Cancer Senior Commissioning manager Cancer
01.01.2025 –
01.04.2025 Communications with staff, stakeholders and wider public 3a Work with the DDICB Cancer clinical lead and senior commissioning manager to re inclusion of information in the following. o Primary Care bulletin o Items in staff and stakeholder bulletins o Item in the Joined Up Care Derbyshire newsletter o News article o Social media o Circulate communications to our system stakeholders to include in their comms channels (including community groups) Campaigns Manager
01.04.2025 Record Keeping 4a The DDICB will also liaise with HUB+ to discuss the possibility of Record Keeping being added to their suite of online information and support for general practice. Asst Director N&Q PC Email sent 29.11.2024 4b At the Clinical Governance Leads meeting with general practice the below documents will be Asst Director N&Q PC
01.05.2025 A8
discussed as part of the Patient safety standard agenda item. A9
Sent To
- Department of Health and Social Care
- Derby and Derbyshire Integrated Care Board
Response Status
Linked responses
2 of 2
56-Day Deadline
10 Dec 2024
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
Report Sections
Investigation and Inquest
On 8th April 2024 I commenced an investigation into the death of Stephen Charles STRINGER .The investigation concluded on the 25thSeptember 2024 and the conclusion was one of Narrative: Died from squamous cell carcinoma of the glottis where the significance of his symptoms including a prolonged period of hoarse voice was not appreciated until the cancer had progressed to Stage 4.The medical cause of death was 1a Squamous cell carcinoma of the glottis; II Asbestos-related interstitial lung disease, Ischaemic heart disease
Circumstances of the Death
Stephen Charles Stringer developed a hoarse voice from January 2023. The prolonged nature of his hoarse voice and its ongoing deterioration was not explored in detail or noted as a potential cancer red flag until 23rd October 2023. He was referred at that point on the 2 week wait to ENT. He was diagnosed by biopsy on 9th January 2024 with stage 4 squamous cell carcinoma of the glottis. He was treated palliatively. Earlier referral to ENT would probably have led to earlier detection of the cancer and increased the treatment options available.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.