Michael Amesbury
PFD Report
All Responded
Ref: 2023-0259
All 1 response received
· Deadline: 13 Sep 2023
Coroner's Concerns (AI summary)
Incompatible information systems and reliance on postal services delayed critical patient referrals and image transfers between trusts, compounded by a shortage of cardiology clinicians, hindering timely treatment.
View full coroner's concerns
1. The inquest heard evidence that Mr Amesbury needed to be referred from secondary to tertiary services within Greater Manchester. The inquest heard evidence that the speed and quality of that referral was impacted by the way in which information was shared between clinicians in different trusts within Greater Manchester. The use of different systems and reliance on postal services and lack of a clear, effective electronic system of referrals including transfer of images /notes meant there were delays in assessing patients which led to a delay in formulating a treatment plan in tertiary services;
2. The evidence also indicated that there were delays in patients who had been identified as requiring cardiology input being seen in cardiology clinics due to availability of clinicians/appointment slots inquest. This was exacerbated where there was a need for trans oesophageal echocardiogram due to resource issues. The inquest heard that this type of echocardiogram could be key in understanding the cardiac issues of a patient.
2. The evidence also indicated that there were delays in patients who had been identified as requiring cardiology input being seen in cardiology clinics due to availability of clinicians/appointment slots inquest. This was exacerbated where there was a need for trans oesophageal echocardiogram due to resource issues. The inquest heard that this type of echocardiogram could be key in understanding the cardiac issues of a patient.
Responses
Action Planned
NHS Greater Manchester plans to scale and spread the Patient Pass model of care within the GM ICS, leveraging the installed user base and existing clinical pathways. Deployment at an ICS level would enable complex case transfers and out-patient planning to be managed at a higher and more efficient level. (AI summary)
NHS Greater Manchester plans to scale and spread the Patient Pass model of care within the GM ICS, leveraging the installed user base and existing clinical pathways. Deployment at an ICS level would enable complex case transfers and out-patient planning to be managed at a higher and more efficient level. (AI summary)
View full response
Dear Ms Mutch,
Re: Regulation 28 Report to Prevent Future Deaths
Thank you for your Regulation 28 Report dated 19th July 2023 concerning the sad death of Michael Kevin Amesbury on the 30th November 2022 . On behalf of NHS Greater Manchester Integrated Care (NHS GM), we would like to begin by offering our sincere condolences to Mr. Amesbury’s family for their loss.
Thank you for highlighting your concerns during Mr. Amesbury’s Inquest which concluded on 25th of May
2023. 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.
Following the inquest, you raised concerns in your Regulation 28 Report to NHS GM that there is a risk a future death will occur unless action is taken. The medical cause of death was 1a) Bilateral Bronchopneumonia and aspiration of gastric contents; II) Heart Failure, Diabetes Mellitus, Dapagliflozin therapy
I hope the response below demonstrates to you and Mr Amesbury’s family that NHS GM has taken the concerns you have raised seriously and we will learn from this as a whole system.
This letter addresses the issues that fall within the remit of NHSGM and how we can share the learning from this case.
The inquest heard evidence that Mr Amesbury needed to be referred from secondary to tertiary services within Greater Manchester. The inquest heard evidence that the speed and quality of that referral was impacted by the way in which information was shared between clinicians in different trusts within Greater Manchester. The use of different systems and reliance on postal services and lack of a clear, effective electronic system of referrals including transfer of images /notes meant there were delays in assessing patients which led to a delay in formulating a treatment plan in tertiary services.
Inter-operability of different information technology systems to enable efficient and effective communication across primary care, secondary care, tertiary care and wider system partners continues to be a challenge for all health and care systems nationally.
Interoperability of systems between tertiary and secondary care is a difficult issue that we have been
4th Floor, Piccadilly Place, Manchester M1 3BN Tel: 0161 6257791 www.gmintegratedcare.org.uk exploring. Attached as appendix 1 is a briefing note which outlines how a secondary to tertiary referral platform (Patient Pass) has been used to excellent effect in Renal, Neurosurgery and Plastics services at Northern Care Alliance (NCA). There are significant benefits for outcomes re safety and productivity. We are looking at how we can bring the benefits of this type of technology to other services.
Health and social care organisations in Greater Manchester have established the GM Care Record (GMCR), a shared care record which amalgamates essential information for 2.8 million citizens and is used by health and social care professionals for direct care across the region’s 10 localities. However the GMCR does not address system operability between tertiary and secondary care, therefore we must procure this through alternative suppliers e.g. Patient Pass. The GMCR can sit alongside this technology.
Work to resolve this aligns closely with the GM digital strategy, the opportunities that the ICB brings for visibility, spread and scale. GM ICB commits to exploring and as appropriate, implementing this across other GM services. We will be progressing this with chief information officers across the integrated care system for an outline discussion to consider how this could be worked up into a funded project within the strategy delivery plan.
The evidence also indicated that there were delays in patients who had been identified as requiring cardiology input being seen in cardiology clinics due to availability of clinicians/appointment slots inquest. This was exacerbated where there was a need for trans- oesophageal echocardiogram due to resource issues. The inquest heard that this type of echocardiogram could be key in understanding the cardiac issues of a patient.
Radiologist shortages are being experienced nationally, with a 15% vacancy rate across Greater Manchester at consultant grade.
The Greater Manchester Imaging Network are supporting the upskilling and change of skill mix within the Imaging workforce by allocating funding for reporting radiographers, focusing on computerised tomography (CT) and magnetic resonance imaging (MRI) reporting radiographers. Furthermore, the network are coordinating international recruitment via community diagnostic centres (CDC) funding stream to bring in more radiologists.
The Imaging network are exploring the use of a collaborative staff bank, including CT, to reduce reliance on agencies etc. Also, the use of Picture Archiving and Communication System (PACS) based reporting in future will be an enabler for an insourcing model or more centralised service to be used for reporting. PACS are Picture and Communication Systems, which provide economical storage and convenient access to images from multiple modalities and could therefore be used as central storage systems that can be used across GM, reducing the staffing resource required to do the reporting. The implementation of PACS is currently a key scheme within the Imaging Digital Programme.
Actions taken or being taken to share learning across Greater Manchester:
1. Learning to be presented/shared with the Greater Manchester System Quality Group on the 16 of November 2023. This meeting is attended by a broad range of system leaders, including, clinical and care leaders, commissioners of specialist services, locality representatives from each of the 10 GM boroughs, the CQC, Healthwatch who represent the public voice and NICE. Through sharing in this forum, we expect members to review and ensure learning is incorporated into their commissioned services.
4th Floor, Piccadilly Place, Manchester M1 3BN Tel: 0161 6257791 www.gmintegratedcare.org.uk
2. To discuss at the GM Digital Delivery Executive in October 2023 for an outline discussion to consider how this could be worked up into a funded project within the strategy delivery plan.
3. Shared learning from this and similar cases at Greater Manchester and borough level will be cascaded to professionals through relevant governance and learning forums to ensure that learning is incorporated into their services.
In conclusion, key learning points and recommendations will be monitored to ensure they are embedded within practice. NHS GM is committed to improving outcomes for the population of Greater Manchester.
I hope this response demonstrates to you and Mr. Amesbury’s family that NHS GM has taken the concerns you have raised seriously and is committed to working together as a system including our service users, carers and families to improve the care provided.
Thank you for bringing these important patient safety issues to our attention and please do not hesitate to contact me should you need any further information.
Re: Regulation 28 Report to Prevent Future Deaths
Thank you for your Regulation 28 Report dated 19th July 2023 concerning the sad death of Michael Kevin Amesbury on the 30th November 2022 . On behalf of NHS Greater Manchester Integrated Care (NHS GM), we would like to begin by offering our sincere condolences to Mr. Amesbury’s family for their loss.
Thank you for highlighting your concerns during Mr. Amesbury’s Inquest which concluded on 25th of May
2023. 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.
Following the inquest, you raised concerns in your Regulation 28 Report to NHS GM that there is a risk a future death will occur unless action is taken. The medical cause of death was 1a) Bilateral Bronchopneumonia and aspiration of gastric contents; II) Heart Failure, Diabetes Mellitus, Dapagliflozin therapy
I hope the response below demonstrates to you and Mr Amesbury’s family that NHS GM has taken the concerns you have raised seriously and we will learn from this as a whole system.
This letter addresses the issues that fall within the remit of NHSGM and how we can share the learning from this case.
The inquest heard evidence that Mr Amesbury needed to be referred from secondary to tertiary services within Greater Manchester. The inquest heard evidence that the speed and quality of that referral was impacted by the way in which information was shared between clinicians in different trusts within Greater Manchester. The use of different systems and reliance on postal services and lack of a clear, effective electronic system of referrals including transfer of images /notes meant there were delays in assessing patients which led to a delay in formulating a treatment plan in tertiary services.
Inter-operability of different information technology systems to enable efficient and effective communication across primary care, secondary care, tertiary care and wider system partners continues to be a challenge for all health and care systems nationally.
Interoperability of systems between tertiary and secondary care is a difficult issue that we have been
4th Floor, Piccadilly Place, Manchester M1 3BN Tel: 0161 6257791 www.gmintegratedcare.org.uk exploring. Attached as appendix 1 is a briefing note which outlines how a secondary to tertiary referral platform (Patient Pass) has been used to excellent effect in Renal, Neurosurgery and Plastics services at Northern Care Alliance (NCA). There are significant benefits for outcomes re safety and productivity. We are looking at how we can bring the benefits of this type of technology to other services.
Health and social care organisations in Greater Manchester have established the GM Care Record (GMCR), a shared care record which amalgamates essential information for 2.8 million citizens and is used by health and social care professionals for direct care across the region’s 10 localities. However the GMCR does not address system operability between tertiary and secondary care, therefore we must procure this through alternative suppliers e.g. Patient Pass. The GMCR can sit alongside this technology.
Work to resolve this aligns closely with the GM digital strategy, the opportunities that the ICB brings for visibility, spread and scale. GM ICB commits to exploring and as appropriate, implementing this across other GM services. We will be progressing this with chief information officers across the integrated care system for an outline discussion to consider how this could be worked up into a funded project within the strategy delivery plan.
The evidence also indicated that there were delays in patients who had been identified as requiring cardiology input being seen in cardiology clinics due to availability of clinicians/appointment slots inquest. This was exacerbated where there was a need for trans- oesophageal echocardiogram due to resource issues. The inquest heard that this type of echocardiogram could be key in understanding the cardiac issues of a patient.
Radiologist shortages are being experienced nationally, with a 15% vacancy rate across Greater Manchester at consultant grade.
The Greater Manchester Imaging Network are supporting the upskilling and change of skill mix within the Imaging workforce by allocating funding for reporting radiographers, focusing on computerised tomography (CT) and magnetic resonance imaging (MRI) reporting radiographers. Furthermore, the network are coordinating international recruitment via community diagnostic centres (CDC) funding stream to bring in more radiologists.
The Imaging network are exploring the use of a collaborative staff bank, including CT, to reduce reliance on agencies etc. Also, the use of Picture Archiving and Communication System (PACS) based reporting in future will be an enabler for an insourcing model or more centralised service to be used for reporting. PACS are Picture and Communication Systems, which provide economical storage and convenient access to images from multiple modalities and could therefore be used as central storage systems that can be used across GM, reducing the staffing resource required to do the reporting. The implementation of PACS is currently a key scheme within the Imaging Digital Programme.
Actions taken or being taken to share learning across Greater Manchester:
1. Learning to be presented/shared with the Greater Manchester System Quality Group on the 16 of November 2023. This meeting is attended by a broad range of system leaders, including, clinical and care leaders, commissioners of specialist services, locality representatives from each of the 10 GM boroughs, the CQC, Healthwatch who represent the public voice and NICE. Through sharing in this forum, we expect members to review and ensure learning is incorporated into their commissioned services.
4th Floor, Piccadilly Place, Manchester M1 3BN Tel: 0161 6257791 www.gmintegratedcare.org.uk
2. To discuss at the GM Digital Delivery Executive in October 2023 for an outline discussion to consider how this could be worked up into a funded project within the strategy delivery plan.
3. Shared learning from this and similar cases at Greater Manchester and borough level will be cascaded to professionals through relevant governance and learning forums to ensure that learning is incorporated into their services.
In conclusion, key learning points and recommendations will be monitored to ensure they are embedded within practice. NHS GM is committed to improving outcomes for the population of Greater Manchester.
I hope this response demonstrates to you and Mr. Amesbury’s family that NHS GM has taken the concerns you have raised seriously and is committed to working together as a system including our service users, carers and families to improve the care provided.
Thank you for bringing these important patient safety issues to our attention and please do not hesitate to contact me should you need any further information.
Sent To
- Greater Manchester Integrated Care
Response Status
Linked responses
1 of 1
56-Day Deadline
13 Sep 2023
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 6th December 2022 I commenced an investigation into the death of Michael Kevin Amesbury. The investigation concluded on the 25th May 2023 and the conclusion was one of Narrative: Died from a combination of bronchopneumonia (not diagnosed until after death) and aspiration of gastric contents exacerbated by heart failure for which he was awaiting assessment regarding his suitability for surgical intervention. The medical cause of death was 1a) Bilateral Bronchopneumonia and aspiration of gastric contents; II) Heart Failure, Diabetes Mellitus, Dapagliflozin therapy
Circumstances of the Death
Michael Kevin Amesbury had an extensive cardiac history. He was becoming increasingly unwell as a consequence. On 24th October 2022 he had a trans-oesophageal echocardiogram that confirmed he had severe mitral regurgitation. He was referred to Wythenshawe Hospital for surgical assessment. Whilst awaiting assessment he became increasingly unwell. He was prescribed Dapagliflozin medication which led to a rapid rise in his ketones and he became increasingly unwell. He was admitted to Tameside General Hospital on 30th November 2022 .Whilst an in-patient at Tameside General Hospital he became unresponsive. Cardiopulmonary resuscitation was undertaken during which there was severe vomiting of gastric contents. He died at Tameside General Hospital on 30th November 2022. Post-mortem examination confirmed he had died from bilateral bronchopneumonia (not diagnosed in life) in combination with extensive aspiration of gastric contents. He had extensive evidence of heart failure which on the balance of possibilities contributed to his reduced physiological reserves and to his death.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.