Regulation 28: Report to Prevent Future Deaths (PFD)

REGULATION 28: REPORT TO PREVENT FUTURE DEATHS

Date: 5th May 2024 Version: V3 Author:

Regulation 28: Report to Prevent Future Deaths (PFD)

Contents Introduction ........................................................................................................................... 5 Action Plan ............................................................................................................................ 5 Immediate Actions Taken .................................................................................................... 5 Short-term Improvements ................................................................................................... 5 Formal Reviews: ............................................................................................................. 5 Individual Feedback: ....................................................................................................... 5 Staff Training on Message Escalation: .............................................................................. 5 Care Navigation and Escalation Training: ......................................................................... 6 GP Observation of Reception Staff: .................................................................................. 6 Long-term Strategy and Improvements ................................................................................ 6 Enhanced Communication Systems ................................................................................ 6 Comprehensive Staff Training Program ............................................................................. 7 Policy and Procedure Review ........................................................................................... 7 Monitoring and Evaluation ............................................................................................... 8 Patient Engagement and Feedback .................................................................................. 8 Appendix 1 ......................................................................................................................... 9 Team Meeting Minutes - 18/3/24 .......................................................................................... 9 Reception Notification Protocol: ...................................................................................... 9 Induction Policy Review: .................................................................................................. 9 Red Button Training: ........................................................................................................ 9 Mandatory Training Review: ............................................................................................. 9 Message Book Audit: ....................................................................................................... 9 Confidence and Understanding Survey Results: ............................................................. 12 Protocol and Policy Development: ................................................................................... 9 Appendix 2 ....................................................................................................................... 10 Admin Meeting Minutes - 25/03/2024 - Inquest Meeting ..................................................... 10 Minutes: CS .................................................................................................................. 10 The meeting concluded with a summary of key takeaways: ............................................. 11 Appendix 3 ....................................................................................................................... 13 Clinical Meeting Minutes................................................................................................... 13 Review of Last Minutes: ................................................................................................. 13 Safeguarding & Alerts: ................................................................................................... 13 New Cancer Diagnosis: ................................................................................................. 13 PQES audits discussed: ................................................................................................ 13 Patients Discussed: ...................................................................................................... 14

Regulation 28: Report to Prevent Future Deaths (PFD)

Other Matters - Significant Events/Updates: ................................................................... 14 Summary: ..................................................................................................................... 14 Appendix 4 ....................................................................................................................... 15 Staff training/ meeting 22/4/2024 ...................................................................................... 15 Minutes: ....................................................................................................................... 15 Action: .......................................................................................................................... 16 Appendix 5 ....................................................................................................................... 17 TEAM MEETING 24.4.24 .................................................................................................... 17 Review of last minutes .................................................................................................. 17 Staffing up dates- .......................................................................................................... 17 Incidents/Sig Events- documents, Complaints- .............................................................. 17 MESSAGE BOOK ........................................................................................................... 17 CURRENT ..................................................................................................................... 18 Staff must: .................................................................................................................... 18 Actions for the meeting ................................................................................................. 18 Appendix 6 ....................................................................................................................... 19 Meeting with ICB .............................................................................................................. 19 Appendix 7 ....................................................................................................................... 20 Title: Telephone Call Supervision Audit for Church Elm Lane Medical Practice .................... 20 Introduction: ................................................................................................................. 20 Purpose of the Audit: ..................................................................................................... 20 Audit Methodology: ....................................................................................................... 20 Selection of Sample Calls: ............................................................................................ 20 Recording Review: ........................................................................................................ 20 Evaluation Criteria: ....................................................................................................... 21 Communication effectiveness: ...................................................................................... 21 Information gathering: ................................................................................................... 21 Appointment booking process: ...................................................................................... 21 Escalation of urgent matters: ......................................................................................... 21 Adherence to practice protocols: ................................................................................... 21 Documentation: ............................................................................................................ 21 Feedback...................................................................................................................... 21 Analysis and Reporting: ................................................................................................. 21 Frequency .................................................................................................................... 22 Conclusion: .................................................................................................................. 22 Appendix 8- Call Audits ..................................................................................................... 23

Regulation 28: Report to Prevent Future Deaths (PFD)

Appendix 9 – Message Book Protocol ................................................................................. 24 Appendix 10 ..................................................................................................................... 25 Message Book Audit – 1 Week in March 2024 and 1 Week In April 2024 ............................... 25

Regulation 28: Report to Prevent Future Deaths (PFD)

Introduction This report was requested following the unexpected death of Mr KS in July 2023 due to a myocardial infarction. He called the GP surgery about a referral for back pain, but the call was not escalated. The coroner noted a call back from the GP may not have changed the outcome in Mr KS’s case however it may do in a different case and hence requested a Regulation 28 PFD report to assess how the GP surgery had improved it’s call escalation procedures.

Action Plan

Immediate Actions Taken Immediate actions to address the incident's findings are under development and are being implemented to prevent future occurrences.

Short-term Improvements

Formal Reviews: The details and lessons from this case were shared in clinical and practice meetings after the incident, running up to the inquest and subsequently on specified dates, focusing on learning from the incident to prevent a future recurrence, training, and next steps. This has been discussed internally in team meetings within the practice and externally with the ICB. The ICB meeting was attended by the Associate Medical Director, ICB Head of Primary Care Barking Place and Borough, and Primary Care Lead for Barking and Dagenham on 17/4/24 (Appendix 6)

Individual Feedback: All calls related to KS’s care were reviewed, with feedback provided to the staff members involved and the learning on how to ensure appropriate empathy and support for the caller shared within the team.

Staff Training on Message Escalation: Training sessions were conducted to emphasize the importance of using the auditable message book for call escalation with direct communication with doctors for urgent concerns and screen messages not to be used for any patient-related queries. Two targeted internal training events with clinical and non-clinical staff have taken place to review and implement changes to the process of escalating clinical matters to the clinical team, and following up on this to see if this has been addressed and actioned (Appendix 1, 2, 3).

Regulation 28: Report to Prevent Future Deaths (PFD)

Care Navigation and Escalation Training: Staff were instructed to immediately stop using the screen messaging system for patient or any clinical related matters or communication, favouring the message book and/or direct doctor communication. All staff encouraged to seek help and advice if they were concerned about any patient contact. We are currently in discussions with the ICB (Integrated Care Board) and CEPN (Community Education Provider Network) on how we can access this training on a regular basis, not just for our staff but all staff across Barking and Dagenham.

GP Observation of Reception Staff: To gain an immediate insight of the current situation, a Lead GP has spent time at reception to help staff with queries and to deal with any concerns regarding the message book. With the Lead GP present, staff have been able to ask questions immediately, provide and receive feedback, and gain confidence in the new procedure. To ensure understanding and compliance with training, we are looking at mechanisms to embed systems and processes for regular review and reporting of monitoring and training.

Long-term Strategy and Improvements

The unexpected death of our patient KS highlighted important areas for improvement in our communication and escalation processes. In response to this event, Church Elm Lane Medical Practice (CELMP) has developed a comprehensive long-term strategy to prevent similar incidents. This strategy focuses on enhancing our communication systems, staff training, and patient engagement. Here is an outline of the strategic improvements planned or implemented:

Enhanced Communication Systems

Objective: Implement a robust, failsafe communication system that ensures all patient calls and messages are logged, tracked, and audited effectively. Actions: Use a more reliable clinical messaging system with enhanced audit trails and automatic backup features to prevent data loss. EMIS X (a web-based clinical system) became available in April 2024, enabling us to have an auditable screen messaging system. We are exploring this while we continue to use the tracked message book for patient-related queries. Build a template in EMIS for all urgent communications regarding patients. Timeline: Implementation by Q1 24/25. We are also exploring options such as Elite Tools, to enable more effective triage at the “front door”. Responsible Party: Partners/Practice Manager

Regulation 28: Report to Prevent Future Deaths (PFD)

Comprehensive Staff Training Program

Objective: Develop and implement a continuous, comprehensive training program focusing on communication skills, empathy, and adherence to triage protocols. Actions: Regular training sessions on effective communication, including handling difficult conversations and demonstrating empathy. We have contacted providers for training and have a list of learning needs. Due to contractual restrictions, practices cannot close during core hours for training. We are in discussions with our colleagues to buddy up with another practice so that all staff can be released for training. We will discuss this and share learning at a PCN level as well. We have already engaged with the ICS and ICB regarding this and are waiting for a response. Listening to staff calls on a regular basis and assessing training needs. Following the Coroner's report, we audited a random selection of telephone calls and gave 1:1 feedback (Appendix 7). Scenario-based training on triage protocols to ensure staff are prepared to escalate calls appropriately was undertaken at our training session on 22/4/24, where all non-clinical staff were present. These sessions will be run on a biannual basis (Appendix 4). However, if we need to complete any ad hoc training – based on need, we will. We are also exploring other training offers on this by the ICS and ICB such as training on care navigation and pharmacy first. On Monday mornings which is our busiest times there is a GP at reception to observe and help with queries and navigations. Timeline: Ongoing, with initial sessions starting Q3 23/24 and regular updates thereafter. Responsible Party: Partners/Practice Managers and Clinical Leads.

Policy and Procedure Review

Objective: Conduct a comprehensive review of all practice policies and procedures, especially those related to patient communication and escalation protocols. Actions: Establish a review committee to assess current policies and recommend changes. Update policies to ensure clear, effective protocols are in place for call escalation and emergency situations. This work has already started by engaging with the team; we have looked at the message book, escalation of queries, and training on emergencies face to face. Clinicians are available to discuss any issues. Prior to 1/4/24 patients would call or walk in for appointments at 8am and then at 2pm when the afternoon appointments opened. We now offer all the appointments in the morning so that the system is more streamlined and patients for whom we are unable to offer an appointment at the practice, are signposted to relevant services to ensure their needs are met. Following regular meetings with staff we have developed a Message Book protocol (Appendix 9) and a call supervision audit (Appendix 7) Timeline: Review to begin in Q3 23/24, with updates implemented by Q1 24/25. Responsible Party: Partners/Practice Managers

Regulation 28: Report to Prevent Future Deaths (PFD)

Monitoring and Evaluation

Objective: Implement a monitoring and evaluation framework to regularly assess the effectiveness of communication practices and protocols. Actions: Quarterly audits of communication logs and patient feedback to identify trends and areas for improvement. Ongoing, we will continue to listen to calls on a regular basis for training and development, incorporating this as per usual in our regular staff appraisals (Appendix 7) Quarterly reviews of training effectiveness and staff adherence to updated policies and protocols. Timeline: Framework establishment by Q4 23/24, with ongoing quarterly evaluations. Responsible Party: Partners/Practice Manager

Patient Engagement and Feedback

Objective: As a team, we have reflected deeply on this unfortunate incident. We have met with Mr KS’s family to offer our sincere apology and condolences, reviewed the care given to Mr KS, answered queries regarding the care given and provided copies of the reports and medical details requested by his family. As a team, we have always used patient experiences and feedback to improve our care and will strengthen this engagement by seeking patient opinions. To help our continuous improvement processes. Actions: Implement a more robust patient feedback system with surveys through AccuRx and reflection on themes from patient comments and complaints. Gather insights into patient experiences and areas for improvement from the Friends and Family Test/ GP Survey Feedback including PPG comments. Set up social media sites and a new website making it easier for patients to navigate. Timeline: Feedback system launch by Q1 24/25; social media Q4 23/24. Responsible Party: Partners/Practice Managers and Clinical Leads.

Regulation 28: Report to Prevent Future Deaths (PFD)

Appendix 1 Team Meeting Minutes - 18/3/24

Attendees: MG, AD, KR, SS, ST, SD, CS, JBH, FF, DS, SD

Reception Notification Protocol: Reception staff are to inform patients to let reception know upon arrival so their status on the system can be updated promptly. This action is in response to recent complaints where patients were unaware of the need to report their arrival, resulting in prolonged waiting times. Induction Policy Review: The induction policy for new staff will be reviewed, including the contents of the induction pack. Action item assigned to JBH. Red Button Training: Training on the use of the red button (panic button on EMIS) will be emphasized. It was suggested to include this as a mandatory item on the induction checklist. Mandatory Training Review: JBH to confirm the status of all mandatory training requirements, including sepsis. Discussion included plans for face-to-face training sessions on emergencies, documentation, and navigation. Reception staff to notify JBH of any additional training needs. Message Book Audit: Mehreen audited the message book, and the findings were discussed. It was highlighted that there were discrepancies in what needs to be documented in the message book and the comfort level of reception staff in adding information or raising concerns. Action item: Next session to focus solely on the message book. Protocol and Policy Development: A plan was established to develop a protocol and policy for the message book, led by KR, SS, and JBH Feedback from Inquest: Random telephone audit to be conducted, review of training & review of message book usage as above. Mandate given to ask on-call team when any uncertainty about a patient query & to avoid screen messages for patient related queries.

Regulation 28: Report to Prevent Future Deaths (PFD)

Appendix 2 Admin Meeting Minutes - 25/03/2024 - Inquest Meeting

Attendees: KR, SS, MG, AD, US, RG, CS, SD, SB, GK, DS, ST, LU.

Apologies: JBH, SA, DB, RS, HU, NI, SS.

Minutes: CS

• MG expressed gratitude to everyone for attending the meeting on short notice.

• Apologies for not arranging this sooner; while we may not have all the answers, as a team, we can move forward together. Regarding the incident, it was upsetting and difficult to process. MG emphasized the importance of open communication about feelings within the team. KR, SS, and MG have discussed this matter and shared their thoughts.

• KR distributed paper for attendees to write down any thoughts or reflections.

• MG discussed the events leading up to the incident, including a referral to physiotherapy and subsequent communication breakdowns. A key learning point highlighted was to avoid using screen messages for patient information/queries. Additionally, there was dissatisfaction with the lack of sympathetic communication during the referral process. Further, there was no audit trail indicating access to the patient's notes. MG mentioned speaking with the patient's son the next day, who requested a log of calls, but this was superseded by the coroner's case. The family expressed a belief that earlier communication might have altered the outcome, although the coroner stated otherwise.

• A key learning point emphasized was the necessity of callbacks or escalation to appropriate clinicians to prevent further deaths.

• KR expressed personal distress over the incident and stressed the need for teamwork to improve outcomes.

Regulation 28: Report to Prevent Future Deaths (PFD)

• SD raised a question to reception staff regarding protocols for handling calls related to chest/back pain, with ST responding that calls should prompt a 999 recommendation. Confidence levels in managing medical emergency calls were discussed.

• Training needs were identified regarding the appointment system, signposting, and care navigation.

• LU mentioned the recent release of two hubs and sought feedback on appointment release times. It was agreed to proceed with releases at 8 am only.

• CS highlighted the use of an AccuRx template for situations when no appointments are available, providing alternative avenues for patients.

• KR inquired about confidence levels in communicating with the Duty Doctor, and suggestions for improvement were gathered.

• Screen message usage was discussed, with emphasis placed on using tasks for non- urgent matters and face-to-face communication for urgent issues.

• Training initiatives were proposed, including random audits on telephone calls and training for all staff on call handling.

• GK raised concerns about CQC inspections and their implications, prompting MG to explain the inspection process and the need for teamwork and professionalism.

• MG encouraged open communication and emphasized the availability of anonymous channels for raising concerns - using the CELMP email address to email MG/KR/SS/JBH.

• KR initiated a discussion on the effectiveness of the message book, with suggestions for improvements, including categorization and discussion with all staff.

The meeting concluded with a summary of key takeaways:

• Communication improvement
• Training initiatives
• Importance of teamwork and seeking assistance when uncertain

Regulation 28: Report to Prevent Future Deaths (PFD)

• Listening to patients attentively
• Learning to use the admin communication book for ongoing patient queries.
• Documenting all necessary information properly onto patient records
• MG thanked everyone for their participation, and the meeting adjourned.

Confidence and Understanding Message Book Survey Results: A survey on confidence and understanding regarding the message book yielded the following results: What is your confidence and understanding of what goes onto the message book? Confidence & Understanding: 1 (Lowest) to 10 (Highest) 0: 0 1: 0 2: 0 3: 0 4: 3 5: 3 6: 1 7: 2 8: 1 9: 3 10: 0

Regulation 28: Report to Prevent Future Deaths (PFD)

Appendix 3

Clinical Meeting Minutes

Date: 26/03/2024 CELMP MINUTES: Initials: US

Present: AD, NI, RS, US Apologies: MG, SA, DB, HU

Review of Last Minutes:

Safeguarding & Alerts:

Case 507213 (NI): SS saw the patient, doesn't meet threshold, SS to arrange HV visit (History of DV and substance abuse). Case 509241 (AD): Child in need. Under SS - plans for F/T placement to aunt’s house. Case 505672 (AD): Safeguarding referral sent. Self-harming. Case 507250 (AD): Safeguarding referral sent (sibling to the above). New Cancer Diagnosis:

Case 3039 (NI): Squamous cell carcinoma of lung. Diagnosed via low dose CT screening. Underwent Rt segmentectomy and mediastinal LN resection in Feb 24. Medicines and Prescribing:

PQES audits discussed:

Opioid review (RS): 31 patients reviewed appropriately. Action - 6 monthly pain reviews. Hospital Only Specialist review (RS). MHRA yellow form (RS). MHRA valproate (RS): New men informed of reduced sperm count. SGLT2 (RS): 30 patients audited. Outcome - 10 declined addition of SGLT2 due to side effects.

Regulation 28: Report to Prevent Future Deaths (PFD)

Antibiotic audit (RS): 193 patients given amoxicillin, 117 given 5 days. 69% given for 5 days. Target 75%. COPD inhaler switches (US): Patients on 2 separate inhalers (LABA/ICS + LAMA) to be switched to a single triple therapy. 112 patients reviewed. 4 eligible patients for changing to triple therapy. Patients Discussed:

Case 509549 (NI): 22-year-old with left lateral malleolus fracture 3 months ago; ongoing pain; ankle x-ray – osteopenia ?secondary to disuse. NI to DW radiology for clarification. Case 7292 (NI): 47-year-old - solitary duplex right kidney with cystic tubular structure (from USS in 2017). CKD stage 3 and raised ACR 6.1 – renal A&G Dec 2023. Advised to repeat ACR and refer to urology for cystic tubular structure. Not referred to urology. NI to request another USS renal – if cystic structure present to refer to Urology. Case 479 (NI): Fast AF; using pill in the pocket bisoprolol when symptomatic; Cardio A&G whether appropriate - advised 24hr holter and off bisoprolol. Pt to be advised to ensure has diary with 24hr holter and document time of palpitations and hold off bisoprolol if possible and document when she took tablet to allow accurate interpretation. NI to DW pt re switching to regular diltiazem. Case 506119 (AD): Pt on pregabalin 75mg TDS. Pt Sends eConsult, pt reports that he is been abusing it. Issued 21/2/24 then issued again 4/3/24. NI booked appt to speak to patient. Other Matters - Significant Events/Updates:

Evening Standard article discussed. Referred to Prevention of Future deaths. Suggestions of action plans: Random audits of all telephone calls, clinical and non-clinical. Buddying receptionist – new staff to be buddied with experienced staff for aid. Not to use screen message for clinical questions; use message book/speak F2F with GP. Reception to open message book while on phone with pt. All appointments released in the morning. Training needs to be addressed and arranged.

Summary: PQES discussed. Ensure CD drugs issued every 28 days, not early. Suggested outcomes following inquest.

Regulation 28: Report to Prevent Future Deaths (PFD)

Appendix 4 Staff training/ meeting 22/4/2024

Attendees: Lily, Simmi, Dania, Shanaz, Fabiha, Shannon, Kanika, Sandeep and JBH

Apologies. Carol- covering reception

Minutes:

KR-list what is Urgent and Non urgent on the piece of paper or notebook you have. All staff listed what they thought was urgent and what they thought was non urgent. E.g. chest pain, medication requests etc

Definition of urgent and non-urgent explained and discussed with the team. Chest pain explained and symptoms patients may have and what to do. The different types of chest pain was explained to the team. If patient has chest pain now- call ambulance, give patient option to call or you call the ambulance for him/her. Questions to ask patient with chest pain: Where in the chest is the pain? How long have you had it? It is radiating? Are you short of breath, dizzy, sweating?

Watch utube video’s for asthma and COPD short of breath to see difference between respiratory symptoms and chest pain breathlessness.

Different types of Rash was explained. Rash and temperature – possible Meningitis symptoms and urgent action needed. if just rash then not urgent unless weeping.

Record what was agreed with patient or advice given to patient on pts record. Allergy symptoms- swelling lips/tongue- emergency. shortness of breath

Regulation 28: Report to Prevent Future Deaths (PFD)

Headache symptoms could be a sign of stroke. Face-Arms- Speech, Time (FAST) was explained and symptoms for stroke. Call ambulance for patient as they may not be able to do if they have these symptoms.

Sepsis infection was explained and how the infection goes to the blood and body shuts down. Symptoms: High temperature, short of breath/fast breathing. Change in behaviour of children. Adults may have confusion and dehydration.

Action: Sepsis posters/stroke/heart. Measles outbreak- all staff to be immunised. Let JBH know.

Regulation 28: Report to Prevent Future Deaths (PFD)

Appendix 5

TEAM MEETING 24.4.24

In attendance: Kanika, Lilly, Shannon, Fabiha, Dania, Gloria, Simmi, Manpreet, Sneha, Diane, Heidi

Review of last minutes

Staffing up dates- Manpreet has joined as our new clinician pharmacist Incidents/Sig Events- documents, Complaints-

AOB- New pt checks/reg- are these still being done
- AOB: We are registering new patients and doing new patient checks. After registration, new patients should be invited for a new patient check.
- call dropping -we have had an episode where a call was dropped, Jahanara is looking into this

MESSAGE BOOK Included Not Included Safeguarding RIP notifications E-consultations Hospice, EoL, discharge letters New Hanbury Court patients Sick note extensions Medications - new Urgent request /concerns (if no appointments available please speak to the duty doctor or any of the doctors for advice) Results and scans – if requesting clinician is not available or requested by locum (do not add to Dr task slot ) Patients running out of medication This should be put directly onto the medication request and state the reason for the request. The doctor will do this when they are doing prescriptions.

Regulation 28: Report to Prevent Future Deaths (PFD)

New Sick note requests- this needs an appointment. Degraded allergy notifications- needs to the pharmacist

CURRENT Emis X is now running and enabled. Continue to not use instant messaging with patient information in them. Continue to speak to the relevant person and where appropriate add to message book, Signposting – urgent/non-urgent emergencies/depending on nature of emergency. Use pharmacy first where appropriate, Current documentation processes – all admins to scan documents. Some documents have been scanned on without notifying clinicians. This has been raised as incidents and being investigated. Staff must:

Online documents (emails), read them, note where the documents come from, highlight actions, note medication changes and reconciliate with patient’s medication list on EMIS. If no actions, then file the document. If there is an action, then clinicians need to be alerted by adding to the message book. Book the patient an appointment if needed with the most appropriate clinician. Use message book if there is anything for a clinician to action. Make reference to the document when sending to the relevant clinician. For letters in post, stamp, date and initial the letter before scanning it onto documents or putting in post box for staff (non-patient letters). e-consults: once received, if administrative actions are needed, after adding it onto the message book, then action it and cross off of message book. If clinical action is needed, then it should be left on the message book for the appropriate clinician to access. All QOF related information included must be coded. Continue to use the comment box to help clinicians know which message is for them and highlight any urgency.

Actions for the meeting
- Simmi to contact Rupert who will help with online registration.
- Admin to sign up for training and then regroup.
- If patient declines the health check, then this is patient choice.
- Consequences of missing patient checks mean safeguarding, immunisation history and chronic conditions may be missed. Clinical staff to be extra vigilant regarding this.
- One-off prescription prescribing training required.
- Jahanara looking into call dropping
- Dr Rai will audit 20 scan documents for each admin start and feed back

Regulation 28: Report to Prevent Future Deaths (PFD)

Appendix 6 Meeting with ICB Date: 17th April 2024 Attendees: Simon Clarke (ICB), Benjamin Molyneux (ICB), Dr Mina Goyal (GP partner), Dr Kanika Rai and Sandeep Sharma (new partners @CELMP since 01/04/23), Mrs Jahanara Bahar-Hussain (Practice Manager), Ms Hazera Mahdiya (ICB) Agenda: To discuss the actions taken to prevent further deaths, after the issue of the s28 report Notes:

• Reception staff have been retrained following the incident, and the staff in particular who did not escalate the patient KS’s messages onto the message book have been let go.

• Meetings have been held to discuss communication within the practice.

• Concerning issues that reception/admin staff come across go into a ‘message book’ which is monitored daily (in the AM and PM) – the staff also verbally let the clinical team know when messages have been added into the book.

• Messaging system used to communicate internally with staff is no longer used to pass patient related messages and is only used for social/non patient related messages between staff. This is to ensure no important patient information is lost, practice still deciding whether to use EMIS X for patient related messaging, as this is auditable.

• Random audit of phone calls have been carried out, to assess telephone manner and efficiency of dealing with calls by reception/admin staff. This has identified learning needs for individual staff and they have been trained as appropriate. Staff that have learning needs are reassessed, phone calls are recorded and selected at random to ensure appropriate telephone manner and response to patient queries.

• Ben Molyneux to share a clinical template for call assessing which can use for further audits.

Sandeep Sharma to share the response to the coroner’s report with the ICB, for review.

Regulation 28: Report to Prevent Future Deaths (PFD)

Appendix 7 Title: Telephone Call Supervision Audit for Church Elm Lane Medical Practice

Introduction: Telephone communication plays a vital role in providing healthcare services, enabling patients to access medical advice, book appointments, and seek urgent assistance. Effective telephone call handling is crucial for ensuring patient satisfaction, safety, and quality of care. As part of continuous quality improvement efforts, CELMP has previously conducted regular telephone reviews when patients or staff have raised queries about a call to evaluate the effectiveness of communication, identify areas for improvement, and enhance staff training and performance. A call supervision audit of random calls was conducted to formalise the review of calls following the inquest for Mr KS.

Purpose of the Audit: The primary objective of the telephone call supervision audit is to formally assess the quality of telephone interactions between staff and patients at Church Elm Lane Medical Practice. The audit aims to evaluate various aspects of call handling, including communication/interpersonal skills, information gathering, appointment booking processes, escalation of urgent matters, and adherence to practice protocols. By conducting this audit, the practice seeks to identify strengths and weaknesses in telephone communication, implement targeted interventions for improvement, and ensure consistent delivery of high-quality services to patients.

Audit Methodology: The telephone call supervision audit at Church Elm Lane Medical Practice involves a systematic review of recorded telephone interactions between staff and patients. The audit is conducted by designated personnel which will be the practice manager or the clinical lead. The following steps outline the methodology of the audit:

Selection of Sample Calls: A random sample of telephone calls received by the practice is selected for evaluation. Calls are chosen from different time periods, days of the week, and staff members to ensure a representative sample.

Recording Review: Recorded telephone calls are accessed through the practice's call recording system. Each call is listened to in its entirety to assess the entire interaction between the staff member and the patient.

Regulation 28: Report to Prevent Future Deaths (PFD)

Evaluation Criteria: Calls are evaluated based on predefined criteria, including:

Communication effectiveness: caller ID check, clarity, courtesy, active listening, and empathy.

Information gathering: Accuracy, completeness, and relevance of information collected.

Appointment booking process: Efficiency, accuracy of scheduling, and confirmation of details.

Escalation of urgent matters: Promptness and appropriateness of escalation for urgent medical concerns.

Adherence to practice protocols: Compliance with practice guidelines and procedures for call handling.

Documentation: Detailed notes are taken during the call review process, documenting strengths, areas for improvement, and any deviations from practice protocols.

Feedback Feedback is provided in a structured format, highlighting specific commendable practices and areas requiring attention.

Analysis and Reporting: The findings of the audit are compiled into a comprehensive report. Analysis includes quantitative data on call performance metrics, qualitative observations, and recommendations for improvement.

The report is shared with relevant stakeholders, including practice managers, clinicians, and frontline staff.

Regulation 28: Report to Prevent Future Deaths (PFD)

Frequency For new employees within one month of joining Church Elm Lane. Existing employees at least once a year (in no concerns identified) as part of their appraisal.

Conclusion:

The telephone call supervision audit is a valuable tool for assessing and improving the quality of telephone communication at CELMP. By systematically reviewing recorded calls, identifying areas for improvement, and implementing targeted interventions, the practice can enhance patient satisfaction, safety, and overall service quality. Continuous monitoring and evaluation of telephone call performance are essential components of the practice's commitment to delivering patient-centred care and ensuring excellence in communication standards.

Regulation 28: Report to Prevent Future Deaths (PFD)

Appendix 8- Call Audits

Please see the average % of telephone data analysis for April's 25 calls - only admin calls were given to me to analyse between 15/4/24- 19/04/2024.

Global Data gathering Management Interpersonal skills Total March data - average - Admin 89% 69% 45% 80% 68% April data - average - Admin 89% 62% 42% 86% 67% Movement
-1%
-6%
-3% 6%
-1%

The data summary shows the following:
1. Staff have better telephone manner with greater empathy - well done.
2. Huge training needs that are listed as attached [NB 3 new staff but some other staff identified as would benefit from the training]

It would be helpful to:

1. Check more admin calls after Training delivered.
2. Include some clinical calls in telephone review.
3. Consider reviewing ARRS staff if PCN supervision pathways allow.

Regulation 28: Report to Prevent Future Deaths (PFD)

Appendix 9 – Message Book Protocol Message Book Concerns About Patient If you are worried or concerned about a patient/ letter or email PLEASE SPEAK to the relevant team member Add to the message Book with a comment for the most appropriate clinician If urgent speak directly to clinician and make them aware then add this to the comment below the appointment Concerns but not urgent Concerns about a patient Death Notifications DNA – Children and Cancer patients Emails need action Hospice/ End of Life Care Letters needing actions Letters/ Emails regarding follow ups Med note attentions Results and Scan reports that come via email Safeguarding (Adult or Child) Urgent Requests Vulnerable patient needing an appointment New sick notes Urgent Medication Requests (send to pharmacy) If a venerable patient request it as per normal and add a note to say why Referral queries task to Medical Secretary OK to add Other options

Regulation 28: Report to Prevent Future Deaths (PFD)

Appendix 10 Message Book Audit – 1 Week in March 2024 and 1 Week In April 2024
*Please note Left = Completed
** Gaps are clinical administrative 02-Apr-24 discharge summery uti 26/3/24 Left 02-Apr-24 PLS see discharge summery - re new meds to be added, lu Left 02-Apr-24 sick note extention needs from 25.03.24- 30.04.24 Left 02-Apr-24 is getting chemo done, thinks ,ay have uti? back pain, chemo pt! Telephon e - Complet e 02-Apr-24 suspected uti Left 02-Apr-24 e-consult received. ST Left 02-Apr-24 please see Econsult dated 02.04.24- heavy peiods, fertility issues Left 02-Apr-24 e-consult recieved Left 02-Apr-24 requesting sick note extension, samae ongoing issue, lu Left 02-Apr-24 e-consult recieved / would like fit note extention 28/03/24 - 28/01/2024 ST Left 02-Apr-24 medication changes- please see doc dated 02.04.24 Left 02-Apr-24 need blood test for subcutanous injection Left 02-Apr-24 e-consult received Left 02-Apr-24 fit note extension 4 weeks for cardiac defibrillator Left 02-Apr-24 Patient with high Potassium- have tried this morning unable to contact. Telephon e - Not In 02-Apr-24 sick note extention ongoing issue needs from 1.4.24-30.4.24 Left 02-Apr-24 requesting sick note exrension, expried 1st april, same issue, lu Left 02-Apr-24 e-consult recieved. ST Left 02-Apr-24 please see Econsult dated 2.4.24 Left 02-Apr-24 sick note extention- ongoing issues from 1.4.24- 30.4.24 Left 02-Apr-24 Please discuss at clinical meeting, another SG request Booked 02-Apr-24 suicidal, stressed, depressed, HV req by daughter Zoey as pt is hard to get out the hse Telephon e - Complet e 02-Apr-24 sicknote extention - another month, expired 31-3-24 Left 02-Apr-24 Hv and review fursemide Visited 02-Apr-24 speciment test was not done, pt has been referred back due clinci closing down, pls look n re refer. Telephon e - Complet e 02-Apr-24 pls see 28-3-24 emaill attacment re child in car (cic) Telephon e - Complet e 02-Apr-24 med3 Left

Regulation 28: Report to Prevent Future Deaths (PFD)

02-Apr-24 mental health. rqsting Quetiapine Telephon e - Complet e 03-Apr-24 MXT Telephon e - Complet e 03-Apr-24 requesting antbiotics - uti Left 03-Apr-24 reuesting sick note extension, same issue depression, lu Left 03-Apr-24 discussed in meeting- task Left 03-Apr-24 she need new medication which is not in the system she gave me the name ofthe medication Telephon e - Not In 03-Apr-24 pt needs antibiotics- please see report and emails dated 2.4.24 Booked 03-Apr-24 needs zoplicone and sertaline 50mg urgently to sleep and is anxious Telephon e - Complet e 03-Apr-24 HV Visited 03-Apr-24 nhs 111 call, babys penis swallon, infected? baby is not reg yet Left 03-Apr-24 cs wants to discuss fot for work. insisted on tel call from dr Telephon e - Complet e 03-Apr-24 tonsilitis need antibiotic Left 03-Apr-24 chest pain on going, bloating featque and bp she check is 145/90 Left 03-Apr-24 discus in meeting- task Left 04-Apr-24 please see doc dated 2.4.24 (seen in ENT clinic) Left 04-Apr-24 please see econsult dated 04.04.24- pregnancy, spotting FF Left 04-Apr-24 sick note extension from 04.04.24 - 04.05.24 Left 04-Apr-24 child protection conference, safeguarding children on 24.04.24 for 10am-12pm Left 04-Apr-24 child protection conference, safeguarding children 24.4.24 10- 12pm Left 04-Apr-24 cant move hand cant do a fist Telephon e - Not In 04-Apr-24 sick note extention- ongoing issues on back needs 05.04.24-
30.04.24 Left 04-Apr-24 regarding her med 3. wants to go back to work earrly needs dr to confirm Left 04-Apr-24 pt needs Quetiapine 200mg- please see email dated 4.4.24 Left 04-Apr-24 sodium valproate Telephon e - Complet e 04-Apr-24 Please see Econsult dated 03.04.24 needs referral for endocrinology done Left 04-Apr-24 safeguarding issue please see emails dated 03.4.24 Left 04-Apr-24 meds rejected - chlorphenamine Telephon e -

Regulation 28: Report to Prevent Future Deaths (PFD)

Complet e 04-Apr-24 please see doc dated 02.04.24- please put meds on repeat FF Left 04-Apr-24 meds rejected amvys Left 04-Apr-24 clinical admin Left 04-Apr-24 please see econsult dated 4.4.24 - tired, dizzy FF Left 04-Apr-24 Please see econsult dated 4.4.24 hip problem Left 04-Apr-24 please see econsult dated 04.04.24- severe back pain Left 04-Apr-24 please see PEACE document Telephon e - Complet e 04-Apr-24 child protection conference, safeguarding children 24.04.24 at 10am-12pm Left 04-Apr-24 medication needs to be stopped- please see doc dated 4.4.24 Left 04-Apr-24 please see econsult dated 03.04.24 Eczema, skin issues FF Left 04-Apr-24 new rqst sick note from 10.03.24 - 22.03.24 (stress) Left 04-Apr-24 serious UTI - pt is in extreme pain- no 111 slots FF Telephon e - Complet e 04-Apr-24 cs needs malaria tabs as to young to get from pharmacy Telephon e - Complet e 04-Apr-24 pharmacy called Mr WILSON requesting his as normal for 2 months not for dossett box pls Left 04-Apr-24 ECG results Left 04-Apr-24 cs please see dis summ dated3.4.24 chemical ingestion Left 04-Apr-24
27.03.24 - urology clinic letter, to consider referring for endocrinology Telephon e - Complet e 05-Apr-24 same reason chest infection need to extension fit note 4/4/24 till 19/4/24 Left 05-Apr-24 cs needs arupironal as per DR umme. was told to just ring, going away this weekend Left 05-Apr-24 urine problem Left 05-Apr-24 07/03 new cancer pt see letter thanks Left 05-Apr-24 pt chasing up her medication req, have spoken to anisha Left 05-Apr-24 rashes and spots would like bt Left 05-Apr-24 please see email dated 05.04.24- needs medication Left 05-Apr-24 cs please see 111 dated 21.2.24 Left 05-Apr-24 please see econsultation dated 05.04.24- needed nasal spray Left 05-Apr-24 PT wanted canestan cream, given you the incorrect name Left 05-Apr-24 rash Left 05-Apr-24 cs please see letter from D&E dated 2.2.24 Left 05-Apr-24 saint francis hospice letter received 5/4/24 need urgent prescription request Telephon e -

Regulation 28: Report to Prevent Future Deaths (PFD)

Complet e 05-Apr-24 pharmacy req, pregabalin 50mg out of stock, they can double up 25mg, pls create prescription Telephon e - Complet e 05-Apr-24 please see consultaion from NH from email sent today cs Telephon e - Complet e 05-Apr-24 need urgent antibiotic emailed received from hanbury court Left 05-Apr-24 earache Left 05-Apr-24 medication rqsted today but ot does not have any more left. Left 05-Apr-24 cs please see ent letter dated 29.2.24 Left 05-Apr-24 BREAST SCREENING RESULT Left 05-Apr-24 26/03 d/s please see re gabe pain relif Left 05-Apr-24 medication request consultation 4/4/24 Coloplast Charter Left 05-Apr-24 pls see 29-3-24 pt discharge letter, med to be added, some are there but from last yr, pt needs them urgently, she is a new pt, booked in with yemi Telephon e - Complet e

18-Mar-24 medication Telephon e - Complet e 18-Mar-24 medication Telephon e - Complet e 18-Mar-24 sick note extention for 2mths req Left 18-Mar-24 diabetes Left 18-Mar-24 re med Telephon e - Complet e 18-Mar-24 pt had a CT scan on friday last / on chest at hosp / does he still need to do the chest xray he is asking ? Left 18-Mar-24 patient bp is high checked at the pharmacy Telephon e - Complet e 18-Mar-24 e-consult received Left 18-Mar-24 medication Telephon e -

Regulation 28: Report to Prevent Future Deaths (PFD)

Complet e 18-Mar-24 sick note extention 18.03.24- 08.04.24 Left 18-Mar-24 uss please see from medefer - info Left 18-Mar-24 chest infection Telephon e - Complet e 18-Mar-24 asked to bring in urine Telephon e - Complet e 19-Mar-24 private referral needto change into orthopedic. dr recived a call from the hospital to chnage into orthopedic Telephon e - Complet e 19-Mar-24 ecg report Telephon e - Complet e 19-Mar-24 16/02 letter recurrent cancer Telephon e - Complet e 19-Mar-24 pls see email from saint francis hospice on file Telephon e - Complet e 19-Mar-24 High BP result Telephon e - Complet e 19-Mar-24 please see 13/03 uss report Left 19-Mar-24 econsult sent by pt Left 19-Mar-24 please see letter 18/03 cardiology Left 19-Mar-24 19/03 respiratory please see Left 19-Mar-24 pls see MRI pelvic on file Telephon e - Complet e 19-Mar-24 Error on sick note Telephon e - Complet e 19-Mar-24 pls email on file from pt Left 19-Mar-24 18/03 LETTER PLEASE SEE re breast investigation Telephon e - Complet e 19-Mar-24 please see 14/03 letter repeat bloods - not had any here aince 2019 not sure which ones thanks Left

Regulation 28: Report to Prevent Future Deaths (PFD)

19-Mar-24 extend for fit note fore 3 months mental health isssue. Telephon e - Complet e 19-Mar-24 UCLH - fertility/gynae refferal Left 19-Mar-24 depression- please see econsult dated 19.03.24- Left 19-Mar-24 24 ECG REPORT received pls see on file Left 19-Mar-24 patient is asking 4 tins of powder as per last consultation thanks , dania Left 20-Mar-24 Please check out email from social worker/police 20.03.24 Left 20-Mar-24 pt requested a medication / on clinical letter he is leaving the country at 1pm today he is asking if it can be issued ? Left 20-Mar-24 meds to be added on prescription- please see doc dated
20.03.24 Left 20-Mar-24 please see econsult- shoulder pain Left 20-Mar-24 RE; Sick note Left 20-Mar-24 medications were done on the 18th sent to a pharmacy in birmingham / changed nomination to next door can we re-issue items Left 20-Mar-24 A&G response received Booked 20-Mar-24 please see discharge summary dated 16.03.24- please issue meds and in liquid form- issue asap Left 20-Mar-24 PLS see podiatrist clinic letter 19-3-24 requesting antibiotics Left 20-Mar-24 Phone appt is fine if possible. Her blue inhaler is expired and we need 1 for at home and 1 to keep at school. We already have a spacer. Thanks Telephon e - Complet e 20-Mar-24 email on file re wheelchair Telephon e - Complet e 20-Mar-24 sick note extension - same issue Left 20-Mar-24 safeguarding Left 20-Mar-24 says needs medication urgently, pt says feels like killing herself because of pain. Telephon e - Complet e 20-Mar-24 hanbury crt dropped in prescription needing urgently for lorazepam 500mg Left 20-Mar-24 pls see short stay discharge on file re gp action - emergency as per Carol Left 20-Mar-24 please see email recieved fropm district nurse Left 20-Mar-24 please see last consultation - Xray form needs to be done pt was tld to come in today to collect ? no ntes Left 20-Mar-24 pt says has chest pains and back pain, says dont want to go i to hospital, says its angina pains. Telephon e - Complet e 21-Mar-24 US abdominal on file Left 21-Mar-24 Left

Regulation 28: Report to Prevent Future Deaths (PFD)

21-Mar-24 pls see 21-3-24 email Telephon e - Complet e 21-Mar-24 Left 21-Mar-24 Sore throat, dizzy, stiff neck- Please see Econsult dated 21.03.24 Telephon e - Complet e 21-Mar-24 prescription was put in this morning, says reception said itll be done for this evening Left 21-Mar-24 sick note extention from 23.03.24-05.04.24 ongoing issue- please see econsult dated 21.03.24 Left 21-Mar-24 enquiring about breathing referral Left 21-Mar-24 talatti chemist called to say pt has gone in to req medication for tmrw, as pt is attending funeral tmrw Telephon e - Complet e 21-Mar-24 Telephon e - Complet e 21-Mar-24 need letter regarding her DVT for spire london. hospital need a letter from the gp for blood test Telephon e - Complet e 21-Mar-24 pls see hanbury crt email - pt has a cough Telephon e - Complet e 21-Mar-24 pls see 21-3-24 - hanbury crt email - sore throat Telephon e - Complet e 21-Mar-24 see memory screen assessment and notes thanks HU Left 21-Mar-24 Sick note Left 22-Mar-24 issue supply with the catheter kit / pt came in yesterday /please issue alternative / they have the script just no supply Telephon e - Complet e 22-Mar-24 urine sample requested by GP, patient completed POABX, urine still positive see notes, sent for cult Telephon e - Complet e 22-Mar-24 sick note extention till 29-3-24, no changes. pls text message to pt Telephon e - Complet e 22-Mar-24 sick note Telephon e -

Regulation 28: Report to Prevent Future Deaths (PFD)

Complet e 22-Mar-24
08.03 letter please see info re diagnosis Telephon e - Complet e 22-Mar-24 FF spoe to nurse in porters avenue- mentioned that they need authorisation for flush and needs to be on IV form Telephon e - Complet e 22-Mar-24 was prescribed bisoprolol, since feels itchy, not taken any today, adv contact emergency if further symptoms Telephon e - Complet e 22-Mar-24 pt had a fall on 19.03 and 21.03 hit his head and is struggling- he wanted a home visit Telephon e - Complet e 22-Mar-24 cs med 3 extension long as possible MH Telephon e - Complet e 22-Mar-24 pt wants basic metformin, not has been given, is travelling on monday 25th april, has been speaking to surgery since 19th april Telephon e - Complet e 22-Mar-24 safeguarding email received - requesting information 22.03.2024 Telephon e - Complet e 22-Mar-24 the above named pts wife came in because she needs medication- wife was very angry Telephon e - Complet e 22-Mar-24 econsult 21-3-24 Booked 22-Mar-24 pls see 20-2-24 moorfields letter, pts chloramphenical 0.5% and dexamathason 0.1%, has been prev missed out, urgently in need. Telephon e - Complet e 22-Mar-24 safeguarding email recieved requesting information 22.03.2024 Telephon e - Complet e 22-Mar-24 sick note extention needs 24.03.24-24.04.24 ongoing anxiety disorder FF Telephon e - Complet e 22-Mar-24 MRI SPINE results Telephon e - Complet e

Regulation 28: Report to Prevent Future Deaths (PFD)

22-Mar-24 New patient ran out of Amlodipine usually takes 5mg, has run out of setraline Telephon e - Complet e 22-Mar-24 05/03 d/s safeguarding child Start Call 22-Mar-24 email received on file 20.03.24 from patient Telephon e - Complet e 22-Mar-24 Hanbury Court - chesty Telephon e - Complet e

Please note Left = Completed