Dear Mr. Farrow, Re: Regulation 28 Report to Prevent Future Deaths Thank you for your Regulation 28 Report dated 19 April 24 regarding the sad death of Richard Hardman. On behalf of NHS Greater Manchester Integrated Care (NHS GM), We would like to begin by offering our sincere condolences to Richard’s family for their loss. Thank you for highlighting your concerns during the inquest which concluded on the 20th March 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: - The absence of any obvious mechanism for the various medical disciplines across different hospital sites to be brought together in complex medical cases under the leadership of a single practitioner in a position to evaluate and co-ordinate the best approach and combination of medical care for the patient. This case, as you have described, is very complex in nature and spans specialist services, acute services, and community/primary care services. Generally speaking, the clinician taking care of the most pressing or main issue by default usually take the lead, this is simpler in one setting such as an acute hospital but is complicated when care spans across different settings and services. We have different mechanisms in place that span services to support better communication and co- ordination of care. This includes a ‘joint’ care record that exists across Greater Manchester (the GM Care Record) which holds information from various organisations including GP Practices, Acute Trusts, Adult Social Care (Local Authority) and Mental Health Trusts. Most clinicians have access to this system and to provide an indication of how often it is used, in March 2024, 760 individual acute trust staff accessed records 12,519 times, viewing 7,997 patients. Private & Confidential Mr Adrian Farrow H M Assistant Coroner Coroner’s Court 1 Mount Tabor Street Stockport SK1 3AG A1

4th Floor, Piccadilly Place, Manchester M1 3BN Whilst data tells us that the system is being accessed and patient information being appropriately shared via the GM Care Record, it is acknowledged that not all health care professionals are accessing the benefits of this system. There is a program of work currently underway with a plan to update the web page and re-launch the GM Care Record in early June 2024. The re-launch aims to raise awareness further and eLearning has been updated in addition to which additional training will be provided on how to access and use the system. I have included below links to additional information about the GM Care Record which I hope will be helpful to you: -
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• The GM Care Record - Health Innovation Manchester (info for health & social care teams ) In circumstances where a patient is being cared for across multiple specialist areas, information is shared within the GM Care Record, which supports but is not intended to replace a face-to-face MDT process where the overall care of a patient can be discussed. Technology such as Microsoft Teams enables representatives in multiple organisations’, regardless of location (not just within GM), to ‘meet’ to discuss individual patients and this is a process that happens regularly. In terms of the specialist services provided by the North West Ventilation Unit there is a Long-Term Ventilation Service (LTVS). When dealing with patients with complex medical issues, the LTVS provides regular and "ad hoc” urgent nurse-led and consultant-led appointments. Patients have access to a 24h helpline. When their patients are admitted to another hospital, we have a dedicated staff member to provide advice to those care teams. For frail patients we provide home visits. These complex cases are discussed at the weekly multidisciplinary team meeting that are minuted, and we communicate with other services regularly. This service recognises the need to appoint care coordinators for patients with complex medical needs and progress to achieve this continues. We intend to also take this case to our Clinical Effectiveness Group on the 25th of July 2024, to explore further what more we can do to support complex medical cases. We will also look to check and challenge the robustness of escalation routes from health professionals, patients and families/carers when it comes to concerns, support needs and the provision of equipment. Best wishes A2

Mr Adrian Farrow HM Assistant Coroner Manchester South Coroner’s Court 1 Mount Tabor Street Stockport SK1 3AG

Dear Coroner, Re: Regulation 28 Report to Prevent Future Deaths – Dr Richard George Hardman who died on 07 August 2023

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 19 April 2024 concerning the death of Dr Richard George Hardman on 07 August 2023. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Dr Hardman’s family and loved ones. NHS England are keen to assure the family and the Coroner that the concerns raised about Dr Hardman’s care have been listened to and reflected upon. 

I am grateful for the further time granted to respond to your Report, and I apologise for any anguish this delay may have caused to Dr Hardman’s family or friends. I realise that responses to Coroner Reports can form part of the important process of family and friends coming to terms with what has happened to their loved ones and appreciate this will have been an incredibly difficult time for them.

In your Report, you raised a concern that there was no obvious mechanism for the various medical disciplines across the different hospital sites to be brought together, in complex medical cases, under the leadership of a single practitioner. In Dr Hardman’s case, you raised that the absence of any lead practitioner meant that there was no global oversight of the various complex interacting conditions and care, and the potential for more collaborated, holistic care was clearly apparent.

We note that you have also addressed your Report to the Greater Manchester Integrated Care Board (GM ICB) and they are better placed to address your concern regarding processes across the Greater Manchester system for management of patients with complex medical needs, under the care of different specialties. NHS England has however engaged with GM ICB on the concerns raised. GM ICB advise that there is a ‘joint’ care record that exists across Greater Manchester (the GM Care Record) which holds information from various organisations including GP Practices, Acute Trusts, Adult Social Care (Local Authority) and Mental Health Trusts. Most clinicians have access to this system and, to provide an indication of how often it is used, in March 2024, 760 individual acute trust staff accessed records 12,519 times, viewing 7,997 patients. National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG

8 July 2024 A3

In circumstances where a patient is being cared for across multiple specialist areas, information is shared within the GM Care Record, which supports but is not intended to replace a face-to-face Multidisciplinary Team (MDT) process where the overall care of a patient can be discussed. Technology such as Microsoft Teams enables representatives in multiple organisations, regardless of location (not just within GM), to ‘meet’ to discuss individual patients. We refer you to the response from GM for further information. The Complex Home Ventilation (CHV) Service specification describes the tertiary hospital infrastructure necessary to enable the safe and sustainable establishment and maintenance of home care packages for patients with complex ventilation needs. The overall aim of the specialist service is to establish and support patients with long-term breathing difficulties on the least intrusive ventilation modality possible. This will enable them to have a longer life of better quality than would otherwise be possible.

When dealing with patients with complex medical issues, the Long-Term Ventilation Service (LTVS) within Greater Manchester provides regular and "ad hoc" urgent nurse-led and consultant-led appointments and patients have access to a 24-hour helpline. When their patients are admitted to another hospital, there is a dedicated staff member to provide advice to those care teams and home visits are provide to frail patients. These complex cases are discussed at the weekly Multidisciplinary Team meetings which are minuted and communicated with other services regularly. The service recognises the need to appoint Care Coordinators for patients with complex medical needs.

The issue of access to the LTVS and geographical location has been discussed with my Specialised Commissioning colleagues. There is an LTVS for each Integrated Care Board / System within the North West Region. The LTVS are not responsible for the provision of suction machines, which would be the responsibility of the Community Team to provide. The LTVS should refer any request for a suction machine back to the local/referring clinician/consultant involved in the patient’s care. My regional colleagues in the North West will also be following up with the Manchester University NHS Foundation Trust following a Clinical Effectiveness Group meeting later in July 2024, which will consider the issues raised in your Report.

I would also like to provide further assurances on the national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights are shared across the NHS at both a national and regional level and helps us to pay close attention to any emerging trends that may require further review and action.

Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information.