David Thompson
PFD Report
All Responded
Ref: 2024-0443
All 3 responses received
· Deadline: 7 Oct 2024
Coroner's Concerns (AI summary)
The Priory Dorking's incident review indicated no My Safety Plan was commenced or completed prior to discharge, no engagement with the local Home Based Treatment Team occurred, and there was no consultation with consultants from the Priory in Altrincham; consultant-to-consultant communication was also absent across NHS and private care.
View full coroner's concerns
It is acknowledged that in the case of Mr Thompson there was no evidence any of these concerns caused or contributed to his death. For the Priory - DORKING
1. The Incident Review of his admission to the Priory Dorking indicated that there was no My Safety Plan commenced on admission or complete prior to his discharge.
2. There was no engagement prior to discharge with the local Home Based Treatment Team.
3. There was no consultation with the Consultants who had treated Mr Thompson at the Priory in Altrincham only a few weeks earlier.
4. There was no 48 hour follow up call to Mr Thompson following his discharge, as per Priory Policy.
5. A discharge clinical entry and discharge risk assessment was not completed and there was no evidence of crisis information having been provided.
6. There was no evidence that the four standard care plans had been opened during Mr Thompsons inpatient stay.
7. When conducting the internal review no members of the nursing staff were spoken to to consider why the matters highlighted above had not been carried out. There was therefore a lack of understanding as to whether this was an individual failing or error or a cultural / system failure. Nor was consideration given to whether any individuals should be reported to their regulatory body. For the Priory - ALTRINCHAM
1. On the outpatient appointment in January 2024 the fact that Mr Thompson had been an inpatient in the Priory in Dorking following his discharge from the Priory Altrincham was not known. There was a lack of awareness as to how to access certain parts of the medical records which would have shown this information. Mr Thompson did not volunteer this information so there was no discussion with him as to why he had relapsed so quickly.
2. At the time of his appointment in January 2024 Mr Thompson was not under any NHS community services such as the home based treatment team. This was not recognised or known when formulating his ongoing plan.
3. No internal review was undertaken of Mr Thompsons admission within the Priory Altrincham to consider whether there was any learning For All:
1. There was a complete absence of any Consultant – Consultant discussions or communication, given this patient was receiving care from both the NHS and privately.
1. The Incident Review of his admission to the Priory Dorking indicated that there was no My Safety Plan commenced on admission or complete prior to his discharge.
2. There was no engagement prior to discharge with the local Home Based Treatment Team.
3. There was no consultation with the Consultants who had treated Mr Thompson at the Priory in Altrincham only a few weeks earlier.
4. There was no 48 hour follow up call to Mr Thompson following his discharge, as per Priory Policy.
5. A discharge clinical entry and discharge risk assessment was not completed and there was no evidence of crisis information having been provided.
6. There was no evidence that the four standard care plans had been opened during Mr Thompsons inpatient stay.
7. When conducting the internal review no members of the nursing staff were spoken to to consider why the matters highlighted above had not been carried out. There was therefore a lack of understanding as to whether this was an individual failing or error or a cultural / system failure. Nor was consideration given to whether any individuals should be reported to their regulatory body. For the Priory - ALTRINCHAM
1. On the outpatient appointment in January 2024 the fact that Mr Thompson had been an inpatient in the Priory in Dorking following his discharge from the Priory Altrincham was not known. There was a lack of awareness as to how to access certain parts of the medical records which would have shown this information. Mr Thompson did not volunteer this information so there was no discussion with him as to why he had relapsed so quickly.
2. At the time of his appointment in January 2024 Mr Thompson was not under any NHS community services such as the home based treatment team. This was not recognised or known when formulating his ongoing plan.
3. No internal review was undertaken of Mr Thompsons admission within the Priory Altrincham to consider whether there was any learning For All:
1. There was a complete absence of any Consultant – Consultant discussions or communication, given this patient was receiving care from both the NHS and privately.
Responses
Action Taken
The Priory Group outlined several actions taken in response to the coroner's concerns including audits of patient records, reminders to staff regarding procedures, and reviews of policies related to patient safety plans, discharge processes, and communication with families. They will continue monthly audits and share outcomes in clinical governance reports. (AI summary)
The Priory Group outlined several actions taken in response to the coroner's concerns including audits of patient records, reminders to staff regarding procedures, and reviews of policies related to patient safety plans, discharge processes, and communication with families. They will continue monthly audits and share outcomes in clinical governance reports. (AI summary)
View full response
Dear Ms Kearsley
Mr David Thompson - Response to Regulation 28 report
I write to you in response to the Regulation 28 report Priory received dated 12 August 2024. The report was issued following the Inquest touching the death of Mr David Thompson, which was heard on 31 July 2024.
You raised three areas of concern. The first was regarding Priory Hospital Dorking:
1. The incident review of his admission to the Priory Dorking indicated that there was no My Safety Plan commenced on admission or complete prior to his discharge.
2. There was no engagement prior to discharge with the local Home Based Treatment Team.
3. There was no consultation with the Consultants who had treated Mr Thompson at the Priory in Altrincham only a few weeks earlier.
4. There was no 48-hour follow up call to Mr Thompson following his discharge.
5. A discharge clinical entry and discharge risk assessment was not completed and there was no evidence of crisis information having been provided.
6. There was no evidence that the four standard care plans had been opened during Mr Thompson’s inpatient stay.
7. When conducting the internal review no members of the nursing staff were spoken to, to consider why the matters highlighted above had not been carried out. There was therefore a lack of understanding as to whether this was an individual failing or error or a cultural / system failure. Nor was consideration given to whether any individuals should be reported to their regulatory body.
The second area of concern you raised was regarding Priory Hospital Altrincham:
1. On the outpatient appointment in January 2024, the fact that Mr Thompson had been an inpatient in the Priory in Dorking following his discharge from the Priory Altrincham was not known. There was a lack of awareness as to how to access certain parts of the medical records, which would have shown this information. Mr Thompson did not volunteer this information so there was no discussion with him as to why he had relapsed so quickly.
2. At the time of his appointment in January 2024, Mr Thompson was not under the care of any NHS community services such as the home based treatment team. This was not recognised or known when formulating his ongoing plan.
3. No internal review was undertaken of Mr Thompson’s admission within the Priory Altrincham to consider whether there was any learning. A10
Registered Office: Priory, Fifth Floor, 80 Hammersmith Road, London, W14 8UD Tel:
Registered in England No. 09057543
The third area of concern you raised was addressed to Priory, Greater Manchester Integrated Care Board and Pennine Care NHS Foundation Trust:
1. There was a complete absence of any Consultant to Consultant discussion or communication, given this patient was receiving care from both the NHS and privately.
Response to your concerns regarding Priory Hospital Dorking
Matters of concern 1, 2, 3, 5 and 6
These were all identified by Priory as part of the internal Team Incident Review (TIR) that was undertaken in the days following Mr Thompson’s death. The TIR report was shared with the court ahead of the inquest. It is the purpose of such a review to understand what happened and identify any areas of learning. Action was already being taken to address the learning points identified in accordance with our usual processes. As these were all learnings Priory had already highlighted and were addressing, we were surprised and disappointed that these were listed as matters of concern in the Regulation 28 report, particularly as “It is acknowledged that in the case of Mr Thompson there was no evidence any of these concerns caused or contributed to his death”. A detailed action plan (see appendix 1) offers assurance that these learning points have been taken forward and recent audits have evidenced improvements at Priory Hospital Dorking.
Matter of concern 4 - 48 hour follow up call
In accordance with Priory policy H02 Admission, Transfer and Discharge, a follow up call within 48 hours of discharge is not required if a patient has a confirmed appointment with an NHS community service within 72 hours of their discharge, as was the case for Mr Thompson. This is made clear in the TIR report and therefore this is not a matter that requires further attention.
Matter of concern 7 - limitations of internal review
It was recognised that Mr Thompson had been a recent patient at both Priory Hospital Altrincham and Priory Hospital Dorking and hence why it was considered at the time that inviting representatives from both services to attend a joint TIR was good practice. On reflection, we conclude that we should have hosted a separate TIR at each service, inviting those involved in the care and treatment of the patient (to include nursing colleagues), and thereafter brought together the key findings at a joint meeting attended by the senior managers, to identify any areas for cross service learning. This learning point has since been reiterated to Priory’s Director of Quality and our regional Associate Directors of Nursing and Quality who are responsible for the commissioning and quality review of TIR’s.
Consideration was given at the time (and subsequently as the investigation progressed) as to whether any individuals involved in the care of Mr Thompson should be reported to their regulatory body. Reference was made to The Just Culture Guide, as promoted by NHS England in the Patient Safety Incident Response Framework. This states that it is rarely appropriate to blame or single out individuals (save for instances of wilful harm or neglect), but instead consider how learning can be implemented on a wider platform. The fair treatment of staff supports a culture of fairness, openness and learning by ensuring staff feel confident to speak up when things go wrong, rather than fearing blame. With that in mind and in light of the facts, Priory considers there is no requirement to refer any individual to their regulatory body in this instance.
A11
Registered Office: Priory, Fifth Floor, 80 Hammersmith Road, London, W14 8UD Tel:
Registered in England No. 09057543
Response to your concerns regarding Priory Hospital Altrincham
Matter of concern 1 - accessing Dorking and Altrincham records
This concern was addressed in the action plan that was embedded within the TIR report and this was shared with the court ahead of the inquest. For this reason, we did not expect this to be a matter of concern listed in the Regulation 28 report. To summarise, when any user opens a patient’s record on CareNotes (Priory’s electronic patient records platform), the system defaults to show only active documents. This is intended to ensure only records relevant to the current episode of care are present. To view records relating to any previous episodes of care, an ‘Entire Record’ tab is to be selected. A reminder of the presence of this function has since been circulated to all Priory colleagues and a prompt to select ‘entire record’ will be added to the admission checklist.
Matter of concern 2 - no reference to NHS community home treatment services
This also relates to the third matter of concern you raised regarding communications between private and NHS services: please see further below for Priory’s response to that concern.
Matter of concern 3 - internal review following incident
A review was undertaken of Mr Thompson’s inpatient admission to Priory Hospital Altrincham and this is recorded within the TIR report that was shared with the court ahead of the inquest, with a detailed timeline embedded and a summary of this period of care. The conclusion of this review was that Mr Thompson received adequate inpatient care and treatment during his inpatient admission to Priory Hospital Altrincham, and he was discharged appropriately into the care of the Home Treatment Team.
Response to your concerns regarding communication between Private and NHS services
Matter of concern 1 - communications between NHS and private services
Priory expect that when a consultant psychiatrist or doctor is gathering background psychiatric information from a patient at the point of their first assessment, professional curiosity should guide the conversation to ascertain whether the patient is currently receiving care or treatment from any other care provider (NHS or private services). Despite recognising this, patients may not wish to disclose the facts of previous or current episodes of treatment for a number of reasons. This is their right.
However, in order to aid consideration and exploration of this by those undertaking the initial admission assessment, the inpatient admission template on CareNotes has recently been amended, and now includes a field specific to ‘Any current NHS or private service involvement in care’. Inclusion of this field will act as a prompt to encourage discussion with the patient to establish the arrangements and details of any other current care providers involved in the patient’s care.
To ensure a similar question is asked at the first point of contact for Priory outpatients, a question has now been added to the referral form in use by Priory’s central customer service contact centre, ‘Are you under the care of any other service?’. This information gathered at first contact is shared with the allocated consultant for their review and to aid discussion during the first outpatient assessment.
A12
Registered Office: Priory, Fifth Floor, 80 Hammersmith Road, London, W14 8UD Tel: 020 7605 0910 Fax: 020 7605 0911 info@priorygroup.com www.priorygroup.com Registered in England No. 09057543
Upon receipt of details about any external services involved in a patient’s care, it may be appropriate to make contact with these organisations but this will be dependent on the detail of the information made available and whether the patient consents to such contact being made.
To ensure this learning point is reiterated to all consultants across Priory, the importance of identification and liaison (where appropriate) with external organisations involved in the care and treatment of a patient was raised at: Priory’s Acute service network meeting on 25 September 2024; and The Private and Wellbeing service network meeting on 1 October 2024 These meetings are chaired by the Network Clinical Directors (senior doctors within the organisation) for discussion and noting by all in attendance (including Hospital Directors, Consultant Psychiatrists, Directors of Clinical Services, Ward Managers, Senior Nurses and other healthcare professionals). Minutes of the meeting are thereafter circulated to all relevant colleagues for onward sharing as required.
This learning point has also been included in a learning cascade that was issued to all site leaders and thereafter disseminated to all hospital colleagues on 12 September 2024.
It is important to mention that whilst Priory have made advances to the systems and process in place to gather these details and encourage our multi-disciplinary teams to facilitate such contact (with patient consent), all correspondence relating to a patient’s admission, discharge and outpatient care is shared with a patient’s GP (with patient consent). The patient’s GP remains the central coordinator of a patient’s care. Other care services involved in a patient’s care and treatment can request access to this information via the GP. Should an external service (whether private or NHS) seek additional detail to the information held by the GP, Priory clinicians will make themselves available, at short notice if required, to engage in discussions about a patient’s care and treatment.
We will carefully review the responses submitted by Greater Manchester Integrated Care Board and Pennine Care NHS Foundation Trust to this Regulation 28 report to ensure our approaches align.
I trust that the actions outlined above will provide the assurances you seek in respect of this matter.
Mr David Thompson - Response to Regulation 28 report
I write to you in response to the Regulation 28 report Priory received dated 12 August 2024. The report was issued following the Inquest touching the death of Mr David Thompson, which was heard on 31 July 2024.
You raised three areas of concern. The first was regarding Priory Hospital Dorking:
1. The incident review of his admission to the Priory Dorking indicated that there was no My Safety Plan commenced on admission or complete prior to his discharge.
2. There was no engagement prior to discharge with the local Home Based Treatment Team.
3. There was no consultation with the Consultants who had treated Mr Thompson at the Priory in Altrincham only a few weeks earlier.
4. There was no 48-hour follow up call to Mr Thompson following his discharge.
5. A discharge clinical entry and discharge risk assessment was not completed and there was no evidence of crisis information having been provided.
6. There was no evidence that the four standard care plans had been opened during Mr Thompson’s inpatient stay.
7. When conducting the internal review no members of the nursing staff were spoken to, to consider why the matters highlighted above had not been carried out. There was therefore a lack of understanding as to whether this was an individual failing or error or a cultural / system failure. Nor was consideration given to whether any individuals should be reported to their regulatory body.
The second area of concern you raised was regarding Priory Hospital Altrincham:
1. On the outpatient appointment in January 2024, the fact that Mr Thompson had been an inpatient in the Priory in Dorking following his discharge from the Priory Altrincham was not known. There was a lack of awareness as to how to access certain parts of the medical records, which would have shown this information. Mr Thompson did not volunteer this information so there was no discussion with him as to why he had relapsed so quickly.
2. At the time of his appointment in January 2024, Mr Thompson was not under the care of any NHS community services such as the home based treatment team. This was not recognised or known when formulating his ongoing plan.
3. No internal review was undertaken of Mr Thompson’s admission within the Priory Altrincham to consider whether there was any learning. A10
Registered Office: Priory, Fifth Floor, 80 Hammersmith Road, London, W14 8UD Tel:
Registered in England No. 09057543
The third area of concern you raised was addressed to Priory, Greater Manchester Integrated Care Board and Pennine Care NHS Foundation Trust:
1. There was a complete absence of any Consultant to Consultant discussion or communication, given this patient was receiving care from both the NHS and privately.
Response to your concerns regarding Priory Hospital Dorking
Matters of concern 1, 2, 3, 5 and 6
These were all identified by Priory as part of the internal Team Incident Review (TIR) that was undertaken in the days following Mr Thompson’s death. The TIR report was shared with the court ahead of the inquest. It is the purpose of such a review to understand what happened and identify any areas of learning. Action was already being taken to address the learning points identified in accordance with our usual processes. As these were all learnings Priory had already highlighted and were addressing, we were surprised and disappointed that these were listed as matters of concern in the Regulation 28 report, particularly as “It is acknowledged that in the case of Mr Thompson there was no evidence any of these concerns caused or contributed to his death”. A detailed action plan (see appendix 1) offers assurance that these learning points have been taken forward and recent audits have evidenced improvements at Priory Hospital Dorking.
Matter of concern 4 - 48 hour follow up call
In accordance with Priory policy H02 Admission, Transfer and Discharge, a follow up call within 48 hours of discharge is not required if a patient has a confirmed appointment with an NHS community service within 72 hours of their discharge, as was the case for Mr Thompson. This is made clear in the TIR report and therefore this is not a matter that requires further attention.
Matter of concern 7 - limitations of internal review
It was recognised that Mr Thompson had been a recent patient at both Priory Hospital Altrincham and Priory Hospital Dorking and hence why it was considered at the time that inviting representatives from both services to attend a joint TIR was good practice. On reflection, we conclude that we should have hosted a separate TIR at each service, inviting those involved in the care and treatment of the patient (to include nursing colleagues), and thereafter brought together the key findings at a joint meeting attended by the senior managers, to identify any areas for cross service learning. This learning point has since been reiterated to Priory’s Director of Quality and our regional Associate Directors of Nursing and Quality who are responsible for the commissioning and quality review of TIR’s.
Consideration was given at the time (and subsequently as the investigation progressed) as to whether any individuals involved in the care of Mr Thompson should be reported to their regulatory body. Reference was made to The Just Culture Guide, as promoted by NHS England in the Patient Safety Incident Response Framework. This states that it is rarely appropriate to blame or single out individuals (save for instances of wilful harm or neglect), but instead consider how learning can be implemented on a wider platform. The fair treatment of staff supports a culture of fairness, openness and learning by ensuring staff feel confident to speak up when things go wrong, rather than fearing blame. With that in mind and in light of the facts, Priory considers there is no requirement to refer any individual to their regulatory body in this instance.
A11
Registered Office: Priory, Fifth Floor, 80 Hammersmith Road, London, W14 8UD Tel:
Registered in England No. 09057543
Response to your concerns regarding Priory Hospital Altrincham
Matter of concern 1 - accessing Dorking and Altrincham records
This concern was addressed in the action plan that was embedded within the TIR report and this was shared with the court ahead of the inquest. For this reason, we did not expect this to be a matter of concern listed in the Regulation 28 report. To summarise, when any user opens a patient’s record on CareNotes (Priory’s electronic patient records platform), the system defaults to show only active documents. This is intended to ensure only records relevant to the current episode of care are present. To view records relating to any previous episodes of care, an ‘Entire Record’ tab is to be selected. A reminder of the presence of this function has since been circulated to all Priory colleagues and a prompt to select ‘entire record’ will be added to the admission checklist.
Matter of concern 2 - no reference to NHS community home treatment services
This also relates to the third matter of concern you raised regarding communications between private and NHS services: please see further below for Priory’s response to that concern.
Matter of concern 3 - internal review following incident
A review was undertaken of Mr Thompson’s inpatient admission to Priory Hospital Altrincham and this is recorded within the TIR report that was shared with the court ahead of the inquest, with a detailed timeline embedded and a summary of this period of care. The conclusion of this review was that Mr Thompson received adequate inpatient care and treatment during his inpatient admission to Priory Hospital Altrincham, and he was discharged appropriately into the care of the Home Treatment Team.
Response to your concerns regarding communication between Private and NHS services
Matter of concern 1 - communications between NHS and private services
Priory expect that when a consultant psychiatrist or doctor is gathering background psychiatric information from a patient at the point of their first assessment, professional curiosity should guide the conversation to ascertain whether the patient is currently receiving care or treatment from any other care provider (NHS or private services). Despite recognising this, patients may not wish to disclose the facts of previous or current episodes of treatment for a number of reasons. This is their right.
However, in order to aid consideration and exploration of this by those undertaking the initial admission assessment, the inpatient admission template on CareNotes has recently been amended, and now includes a field specific to ‘Any current NHS or private service involvement in care’. Inclusion of this field will act as a prompt to encourage discussion with the patient to establish the arrangements and details of any other current care providers involved in the patient’s care.
To ensure a similar question is asked at the first point of contact for Priory outpatients, a question has now been added to the referral form in use by Priory’s central customer service contact centre, ‘Are you under the care of any other service?’. This information gathered at first contact is shared with the allocated consultant for their review and to aid discussion during the first outpatient assessment.
A12
Registered Office: Priory, Fifth Floor, 80 Hammersmith Road, London, W14 8UD Tel: 020 7605 0910 Fax: 020 7605 0911 info@priorygroup.com www.priorygroup.com Registered in England No. 09057543
Upon receipt of details about any external services involved in a patient’s care, it may be appropriate to make contact with these organisations but this will be dependent on the detail of the information made available and whether the patient consents to such contact being made.
To ensure this learning point is reiterated to all consultants across Priory, the importance of identification and liaison (where appropriate) with external organisations involved in the care and treatment of a patient was raised at: Priory’s Acute service network meeting on 25 September 2024; and The Private and Wellbeing service network meeting on 1 October 2024 These meetings are chaired by the Network Clinical Directors (senior doctors within the organisation) for discussion and noting by all in attendance (including Hospital Directors, Consultant Psychiatrists, Directors of Clinical Services, Ward Managers, Senior Nurses and other healthcare professionals). Minutes of the meeting are thereafter circulated to all relevant colleagues for onward sharing as required.
This learning point has also been included in a learning cascade that was issued to all site leaders and thereafter disseminated to all hospital colleagues on 12 September 2024.
It is important to mention that whilst Priory have made advances to the systems and process in place to gather these details and encourage our multi-disciplinary teams to facilitate such contact (with patient consent), all correspondence relating to a patient’s admission, discharge and outpatient care is shared with a patient’s GP (with patient consent). The patient’s GP remains the central coordinator of a patient’s care. Other care services involved in a patient’s care and treatment can request access to this information via the GP. Should an external service (whether private or NHS) seek additional detail to the information held by the GP, Priory clinicians will make themselves available, at short notice if required, to engage in discussions about a patient’s care and treatment.
We will carefully review the responses submitted by Greater Manchester Integrated Care Board and Pennine Care NHS Foundation Trust to this Regulation 28 report to ensure our approaches align.
I trust that the actions outlined above will provide the assurances you seek in respect of this matter.
Action Taken
Pennine Care NHS Foundation Trust outlined existing procedures for consultant communication, out-of-area placements, and quality assurance in private hospitals. They highlighted the role of Out of Area Practitioners in monitoring inpatient stays and linking with providers and consultants. (AI summary)
Pennine Care NHS Foundation Trust outlined existing procedures for consultant communication, out-of-area placements, and quality assurance in private hospitals. They highlighted the role of Out of Area Practitioners in monitoring inpatient stays and linking with providers and consultants. (AI summary)
View full response
Dear Ms Kearsley,
RE: Inquest touching on the death of David Thompson
I set out below the Trust’s response to your letter to Pennine Care NHS Foundation Trust and the issuing of a Prevention of Future Deaths Notice (Regulation 28), arising from the inquest into the death of David Thompson. May I take this opportunity to extend my own condolences to the family of David and apologise that you had to raise concerns relating to the services he accessed prior to his sad death. The Trust sets out its response to the point below: For All:
1. There was a complete absence of any Consultant – Consultant discussions or communication, given this patient was receiving care from both the NHS and privately.
Trust Response: The organisation was not aware that David attended an outpatient appointment with at the Priory Hospital, Altrincham and therefore the opportunity for Consultant to Consultant communication to take place did not happen. The organisation’s expectation is for to copy the organisation into David’s clinic letter as per the section of ‘Contributing to continuity of care’ within the General Medical Council’s (GMC) ‘Good Medical Practice.’ The guidance states: 65 Continuity of care is important for all patients, but especially those who may struggle to navigate their healthcare journey or advocate for themselves. Continuity is particularly important when care is shared between teams, between different A4
members of the same team, or when patients are transferred between care providers.
a. You must promptly share all relevant information about patients (including any reasonable adjustments and communication support preferences) with others involved in their care, within and across teams, as required.
b. You must share information with patients5 about:
i. the progress of their care
ii. who is responsible for which aspect of their care
iii. the name of the lead clinician or team with overall responsibility for their care.
c. You must be confident that information necessary for ongoing care has been shared:
i. before you go off duty
ii. before you delegate care, or
iii. before you refer the patient to another health or social care provider.
d. You must check, where practical, that a named clinician or team has taken over responsibility when your role in a patient’s care has ended.
It was ’s evidence that the clinic letter was shared with David’s GP and he expected the GP to then share this information with all other care providers. This is not the responsibility of the GP but the responsibility of the doctor who has seen the patient. This evidence was factually incorrect and it is the view of the organisation’s Medical Director, that this is in breach of the GMC’s Good Medical Practice, which all doctors must follow. In order to provide assurance that Pennine Care NHS Foundation Trust’s doctors are also adhering to this guidance formal communication has been sent to all doctors within the organisation from our Medical Director reminding them of this guidance and the GMC’s stipulation that all doctors must follow this. It also highlights this case and asks the doctors to take particular care if a patient is receiving treatment from both an NHS and private provider and that the private provider will also be copied into any correspondence. The organisation’s Medical Director will also liaise with the Medical Directors of all the private providers that Pennine Care patients are known to be placed. Contact will be made with the Priory, Elysium and Cygnet to raise the profile of this identified issue and to work collaboratively to ensure that this issue does not occur again. Out of Area Bed Placements – Private Provider David received care within Priory Hospital, Altrincham and Priory Hospital, Dorking. He was placed in an out of area bed for the Dorking admission where he was under A5
the care of both an NHS Consultant and a private provider Consultant. This would occur when there are no inpatient beds within the organisation or elsewhere in the Northwest Bed Bureau. A private provider bed may need to be used in these circumstances and this bed would be funded by the Integrated Care Board (ICB). The quality of care provided in these private out of area placements was identified as inconsistent across the board and ensuring quality oversight of these placements was difficult. To minimise this issue and to ensure the quality of care provision within these private placements, Greater Manchester ICB devised a preferred provider list and patients will now only be placed in private provider hospitals where the quality of care in these establishments is assured. If any issues are raised in relation to any of these hospitals, they will be put on a stop list which will mean no patients will be placed in these hospitals going forward until the quality has been raised and assurance is provided that they meet the expected standard. To ensure the quality and consistency of the care of Pennine Care patients who are placed in an out of area private bed, an Out of Area Practitioner is responsible for monitoring the inpatient stay, linking in with the relevant providers and inpatient operational leads to ensure all patients receive support and discharge planning as required. The Out of Area Practitioner is a senior mental health practitioner (Band 7) who sits within the Patient Flow Team. They act as a case manager for that patient including attending ward rounds, keeping key professionals (including all Consultants) updated and involvement in repatriation and discharge planning. There are five of these practitioners within the organisation and each practitioner covers one of the five boroughs in which services are commissioned. This is to ensure that each practitioner has the capacity to be able to fulfil this case manager role and to allow cross cover arrangements to take place during period of absence such as annual leave. This process is outlined within the ‘Out of Area Placement’ Standard Operating Procedure detailing the role and responsibilities of the organisation in relation to this type of bed placement and the organisation’s expectations of the Out of Area Practitioner. I hope that the information within this response has provided you with the assurance that you were seeking in relation to learning from these events. Should you require any further information or clarification on the details within this letter, please do not hesitate to get in touch with me again.
RE: Inquest touching on the death of David Thompson
I set out below the Trust’s response to your letter to Pennine Care NHS Foundation Trust and the issuing of a Prevention of Future Deaths Notice (Regulation 28), arising from the inquest into the death of David Thompson. May I take this opportunity to extend my own condolences to the family of David and apologise that you had to raise concerns relating to the services he accessed prior to his sad death. The Trust sets out its response to the point below: For All:
1. There was a complete absence of any Consultant – Consultant discussions or communication, given this patient was receiving care from both the NHS and privately.
Trust Response: The organisation was not aware that David attended an outpatient appointment with at the Priory Hospital, Altrincham and therefore the opportunity for Consultant to Consultant communication to take place did not happen. The organisation’s expectation is for to copy the organisation into David’s clinic letter as per the section of ‘Contributing to continuity of care’ within the General Medical Council’s (GMC) ‘Good Medical Practice.’ The guidance states: 65 Continuity of care is important for all patients, but especially those who may struggle to navigate their healthcare journey or advocate for themselves. Continuity is particularly important when care is shared between teams, between different A4
members of the same team, or when patients are transferred between care providers.
a. You must promptly share all relevant information about patients (including any reasonable adjustments and communication support preferences) with others involved in their care, within and across teams, as required.
b. You must share information with patients5 about:
i. the progress of their care
ii. who is responsible for which aspect of their care
iii. the name of the lead clinician or team with overall responsibility for their care.
c. You must be confident that information necessary for ongoing care has been shared:
i. before you go off duty
ii. before you delegate care, or
iii. before you refer the patient to another health or social care provider.
d. You must check, where practical, that a named clinician or team has taken over responsibility when your role in a patient’s care has ended.
It was ’s evidence that the clinic letter was shared with David’s GP and he expected the GP to then share this information with all other care providers. This is not the responsibility of the GP but the responsibility of the doctor who has seen the patient. This evidence was factually incorrect and it is the view of the organisation’s Medical Director, that this is in breach of the GMC’s Good Medical Practice, which all doctors must follow. In order to provide assurance that Pennine Care NHS Foundation Trust’s doctors are also adhering to this guidance formal communication has been sent to all doctors within the organisation from our Medical Director reminding them of this guidance and the GMC’s stipulation that all doctors must follow this. It also highlights this case and asks the doctors to take particular care if a patient is receiving treatment from both an NHS and private provider and that the private provider will also be copied into any correspondence. The organisation’s Medical Director will also liaise with the Medical Directors of all the private providers that Pennine Care patients are known to be placed. Contact will be made with the Priory, Elysium and Cygnet to raise the profile of this identified issue and to work collaboratively to ensure that this issue does not occur again. Out of Area Bed Placements – Private Provider David received care within Priory Hospital, Altrincham and Priory Hospital, Dorking. He was placed in an out of area bed for the Dorking admission where he was under A5
the care of both an NHS Consultant and a private provider Consultant. This would occur when there are no inpatient beds within the organisation or elsewhere in the Northwest Bed Bureau. A private provider bed may need to be used in these circumstances and this bed would be funded by the Integrated Care Board (ICB). The quality of care provided in these private out of area placements was identified as inconsistent across the board and ensuring quality oversight of these placements was difficult. To minimise this issue and to ensure the quality of care provision within these private placements, Greater Manchester ICB devised a preferred provider list and patients will now only be placed in private provider hospitals where the quality of care in these establishments is assured. If any issues are raised in relation to any of these hospitals, they will be put on a stop list which will mean no patients will be placed in these hospitals going forward until the quality has been raised and assurance is provided that they meet the expected standard. To ensure the quality and consistency of the care of Pennine Care patients who are placed in an out of area private bed, an Out of Area Practitioner is responsible for monitoring the inpatient stay, linking in with the relevant providers and inpatient operational leads to ensure all patients receive support and discharge planning as required. The Out of Area Practitioner is a senior mental health practitioner (Band 7) who sits within the Patient Flow Team. They act as a case manager for that patient including attending ward rounds, keeping key professionals (including all Consultants) updated and involvement in repatriation and discharge planning. There are five of these practitioners within the organisation and each practitioner covers one of the five boroughs in which services are commissioned. This is to ensure that each practitioner has the capacity to be able to fulfil this case manager role and to allow cross cover arrangements to take place during period of absence such as annual leave. This process is outlined within the ‘Out of Area Placement’ Standard Operating Procedure detailing the role and responsibilities of the organisation in relation to this type of bed placement and the organisation’s expectations of the Out of Area Practitioner. I hope that the information within this response has provided you with the assurance that you were seeking in relation to learning from these events. Should you require any further information or clarification on the details within this letter, please do not hesitate to get in touch with me again.
Action Taken
NHS Greater Manchester Integrated Care has implemented a Multi-Agency Discharge Event (MaDE) process for overseeing Out of Area Placements (OAPs). Since April, they have seen a significant decrease in the amount of patients admitted to 'stop' providers. (AI summary)
NHS Greater Manchester Integrated Care has implemented a Multi-Agency Discharge Event (MaDE) process for overseeing Out of Area Placements (OAPs). Since April, they have seen a significant decrease in the amount of patients admitted to 'stop' providers. (AI summary)
View full response
Dear Ms. Kearsley Re: Regulation 28 Report to Prevent Future Deaths Thank you for your Regulation 28 Report dated 12th August 2024 regarding the sad death of Mr. David Thompson. On behalf of NHS Greater Manchester Integrated Care (NHS GM), We would like to begin by offering our sincere condolences to Davi’s family for their loss. Thank you for highlighting your concerns during the inquest which concluded on the 31st of July 2024. On behalf of NHS GM, we apologise that you have had to bring these matters of concern to our attention. We recognise it is very important to ensure we make the necessary improvements to the quality and safety of future services. During the inquest you identified the following cause for concern: - There was a complete absence of any Consultant – Consultant discussions or communication, given this patient was receiving care from both the NHS and privately. To provide a comprehensive response, we have outlined our response to demonstrate:
• How we oversee Out of Area Placements (OAPs)
• What we would expect in relation to communication between the NHS and any Out of Area (OOA) provider
• Any additional action we feel we need to take in relation to this PFD
1. How we oversee Out of Area Placements (OAPs) Greater Manchester has implemented a system wide, standardised, patient centred MaDE (Multi agency discharge event) process for oversight of OAPs. The primary objectives are to pinpoint and document any barriers in a systematic approach to discharge (for Clinically Ready For Discharge Private & Confidential Ms Joanne Kearsley Senior Coroner for the Coroner area of Manchester North 2nd and 3rd Floor Newgate House Newgate Rochdale OL16 1AT A7
4th Floor, Piccadilly Place, Manchester M1 3BN Tel:
(CRFD)) and/or repatriation (for OAPs). These challenges can be escalated through a three-tiered structure, facilitating best practice and lessons learned across the system. The process is in place across all ten GM localities and includes:
• Locality Patient level meetings - Weekly meetings conducted by MH Trusts with locality stakeholders, addressing barriers to discharge and/or repatriation to GM for patients that are CRFD and OAPs
• Locality Escalation Meetings - Weekly meetings chaired by ICB Deputy-Place Based Lead to review patients that require closer partnership working/senior leadership to address barriers to discharge and/or repatriation to GM for patients that are CRFD and OAPs. and
• The Greater Manchester MADE (Fortnightly meeting with senior MH Trust and ICB leadership (clinical, operational and commissioning) to provide assurance around locality oversight and identify system solutions to complex discharges/repatriation.) This process allows a tracking system of each patient who is placed out of area which gives the system grip and control and enables a high level of oversight. In addition, a dashboard to track OAPS is widely available and updated daily, In addition, a process to monitor the quality, experience and care oversight of each patient has been implemented. A system wide task and finish group oversees the framework in which OAPs “receiving” providers are assigned to a category based on their distance from Greater Manchester and their Quality profile ( which includes CQC rating, local intelligence, and information from the host commissioner). The list is used at the point of admission to support decision making and ensures that when an out of area placement is necessary patients are admitted to the available providers closest to home and there is an adequate level of assurance relating to the provider .This oversight framework is designed in line with both the NHS England Host commissioner guidance and the National Quality Oversight Framework. In the unusual and unfortunate event that a patient is admitted to a provider on the “stop” this is escalated into the ICB for additional monitoring and priority repatriation, a co-designed GM repatriation framework which is applied by both GM MH providers is also in place which ensures consistency. Since implementing the oversight framework in April we can see a significant decrease in the amount of patients who are admitted to providers furthest away from home and where we have the best oversight. There were over 30 patients in April admitted to our “stop” providers and as at 1st Oct 2024 there were 3 patients. Both the MADE structure and the Oversight framework has been designed and implemented in collaboration with all stakeholders and is monitored through the GM MaDE which reports to the GM Mental Health System Group and then onward to the GM ICB Board.
2. What we would expect in relation to communication between the NHS and any OOA provider GM ICB expect the NHS “sending” provider to oversee the individual care relating to any patient who is admitted as an Out of Area placement in line with National Host commissioner guidance. This includes attendance at ward rounds, face to face visits where appropriate and full engagement in discharge and care planning. The processes as described above have been implemented since December 2023 and have provided a much tighter grip and control and increased level of oversight of each individual patient.
3. Any additional action we feel we need to take in relation to this PFD Greater Manchester is working on ensuring these processes are consistent across the system and A8
4th Floor, Piccadilly Place, Manchester M1 3BN Tel:
further defining the practical actions of individual oversight from the care coordination teams relating to those patients admitted into Acute out of area placements, Rehab Beds, Individual non contracted beds and trust beds. This will be considered in line with current capacity levels, the required escalation, and a wider review of MH community services in GM. We will also take this report to the Mental Health Clinical Effectiveness Group for discussion and shared learning. Best wishes A9
• How we oversee Out of Area Placements (OAPs)
• What we would expect in relation to communication between the NHS and any Out of Area (OOA) provider
• Any additional action we feel we need to take in relation to this PFD
1. How we oversee Out of Area Placements (OAPs) Greater Manchester has implemented a system wide, standardised, patient centred MaDE (Multi agency discharge event) process for oversight of OAPs. The primary objectives are to pinpoint and document any barriers in a systematic approach to discharge (for Clinically Ready For Discharge Private & Confidential Ms Joanne Kearsley Senior Coroner for the Coroner area of Manchester North 2nd and 3rd Floor Newgate House Newgate Rochdale OL16 1AT A7
4th Floor, Piccadilly Place, Manchester M1 3BN Tel:
(CRFD)) and/or repatriation (for OAPs). These challenges can be escalated through a three-tiered structure, facilitating best practice and lessons learned across the system. The process is in place across all ten GM localities and includes:
• Locality Patient level meetings - Weekly meetings conducted by MH Trusts with locality stakeholders, addressing barriers to discharge and/or repatriation to GM for patients that are CRFD and OAPs
• Locality Escalation Meetings - Weekly meetings chaired by ICB Deputy-Place Based Lead to review patients that require closer partnership working/senior leadership to address barriers to discharge and/or repatriation to GM for patients that are CRFD and OAPs. and
• The Greater Manchester MADE (Fortnightly meeting with senior MH Trust and ICB leadership (clinical, operational and commissioning) to provide assurance around locality oversight and identify system solutions to complex discharges/repatriation.) This process allows a tracking system of each patient who is placed out of area which gives the system grip and control and enables a high level of oversight. In addition, a dashboard to track OAPS is widely available and updated daily, In addition, a process to monitor the quality, experience and care oversight of each patient has been implemented. A system wide task and finish group oversees the framework in which OAPs “receiving” providers are assigned to a category based on their distance from Greater Manchester and their Quality profile ( which includes CQC rating, local intelligence, and information from the host commissioner). The list is used at the point of admission to support decision making and ensures that when an out of area placement is necessary patients are admitted to the available providers closest to home and there is an adequate level of assurance relating to the provider .This oversight framework is designed in line with both the NHS England Host commissioner guidance and the National Quality Oversight Framework. In the unusual and unfortunate event that a patient is admitted to a provider on the “stop” this is escalated into the ICB for additional monitoring and priority repatriation, a co-designed GM repatriation framework which is applied by both GM MH providers is also in place which ensures consistency. Since implementing the oversight framework in April we can see a significant decrease in the amount of patients who are admitted to providers furthest away from home and where we have the best oversight. There were over 30 patients in April admitted to our “stop” providers and as at 1st Oct 2024 there were 3 patients. Both the MADE structure and the Oversight framework has been designed and implemented in collaboration with all stakeholders and is monitored through the GM MaDE which reports to the GM Mental Health System Group and then onward to the GM ICB Board.
2. What we would expect in relation to communication between the NHS and any OOA provider GM ICB expect the NHS “sending” provider to oversee the individual care relating to any patient who is admitted as an Out of Area placement in line with National Host commissioner guidance. This includes attendance at ward rounds, face to face visits where appropriate and full engagement in discharge and care planning. The processes as described above have been implemented since December 2023 and have provided a much tighter grip and control and increased level of oversight of each individual patient.
3. Any additional action we feel we need to take in relation to this PFD Greater Manchester is working on ensuring these processes are consistent across the system and A8
4th Floor, Piccadilly Place, Manchester M1 3BN Tel:
further defining the practical actions of individual oversight from the care coordination teams relating to those patients admitted into Acute out of area placements, Rehab Beds, Individual non contracted beds and trust beds. This will be considered in line with current capacity levels, the required escalation, and a wider review of MH community services in GM. We will also take this report to the Mental Health Clinical Effectiveness Group for discussion and shared learning. Best wishes A9
Part of a Series
2 separate reports were issued from this inquest, each sent to different organisations.
-
2026-0080
Sent to: Devon & Cornwall PoliceAll responded
This report (2024-0443) is shown above.
Sent To
- NHS Greater Manchester Integrated Care Board
- Pennine Care NHS Foundation Trust
- Priory Group
Response Status
Linked responses
3 of 3
56-Day Deadline
7 Oct 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 the 25th April 2024 I commenced an investigation into the death of Mr David Thompson who died on the 3rd March 2024. The investigation concluded on the 31st July 2024. The medical cause of death was confirmed as 1a) Hypovovalmic Shock 1b) Deep cuts to left wrist 2) Fatty liver disease (alcohol related), Affective disorder, Acute alcohol intoxication. A narrative conclusion was recorded; “On a background of a longstanding diagnosis of Affective disorder of which emotional dysregulation was a feature, the deceased died as a result of self-inflicted stab wounds. His diagnosis together with acute alcohol intoxication suggested on the balance of probabilities that his actions were impulsive and he did not intend to end his life.”
Circumstances of the Death
Mr Thompson had a longstanding diagnosis of bi-polar disorder. Over the years he had also used alcohol and illicit drugs, albeit at the time of his death he had not used drugs for years and had been abstinent from alcohol for several years. He was under the care of Pennine Care NHS Foundation Trust for his mental health. In June 2023 David had self-harmed by cutting himself and had been admitted to Tameside hospital where he remained as an inpatient until 29th August 2023. He also underwent Transcranial Magnetic Stimulation therapy at Royal Oldham hospital until the 23rd September 2023. At the time David had health insurance via his employment so he took the opportunity to undergo further inpatient treatment at the Priory hospital in Altrincham. He was admitted under the care of on the 23rd September 2023. He remained an inpatient until the 19th October 2023. On his discharge Mr Thompson relapsed and was then admitted to the Priory Hospital in Dorking from the 28th October until the 8th November 2023. This was as an NHS patient and the location was due to bed availability. Throughout this time Mr Thompson remained under the care of his NHS Psychiatrist who reviewed him as an outpatient in December 2023. At this time Mr Thompson was stable and a plan was to review him in March 2024. In January 2024 he was reviewed by . This was the outpatient appointment which had been made following his discharge on the 19th October. It is acknowledged that Mr Thompson was stable at this appointment. The plan following this appointment included: “to continue to get input from the local NHS Mental health services.” On the 29th February 2024 Mr Thompson was in Budapest accessing dental treatment when he was advised he may require a biopsy due to a possible abnormality on his gums. He returned home on the 2nd March 2024. He had intimated some level of distress at this news. It is also likely that he relapsed and used alcohol. On his return home he did not wish relatives to stay with him. He then consumed alcohol and cut his wrists. He had attempted to make contact with some family in the middle of the night but due to the time of day his messages were not accessed until the morning.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.