Violet Howard
PFD Report
All Responded
Ref: 2022-0273
All 1 response received
· Deadline: 29 Nov 2022
Coroner's Concerns (AI summary)
There is a critical gap in dermatology commissioning for Royal Oldham Hospital inpatients, excluding those from outside the local area unless their skin condition becomes an emergency.
View full coroner's concerns
(1) There is a gap in the commissioning arrangements for dermatology services covering in-patients at the Royal Oldham Hospital. Those arrangements do not cover in-patients who are from outside of the Oldham area unless and until they become 'emergency dermatological cases' and meet the criteria for input from dermatology at Salford Royal Hospital.
Responses
Noted
NHS Greater Manchester Integrated Care states that the issue is a gap in acute provision rather than a commissioning gap and is being addressed by the Care Organisation via a SLA. Learning will be shared with the Greater Manchester System Quality Group and cascaded to professionals through relevant governance and learning forums. (AI summary)
NHS Greater Manchester Integrated Care states that the issue is a gap in acute provision rather than a commissioning gap and is being addressed by the Care Organisation via a SLA. Learning will be shared with the Greater Manchester System Quality Group and cascaded to professionals through relevant governance and learning forums. (AI summary)
View full response
Dear Ms. McKenna
Re: Regulation 28 Report to Prevent Future Deaths – Violet Elizabeth Howard 26/11/21
Thank you for your Regulation 28 Report dated 05/09/22 concerning the sad death of Violet Elizabeth Howard on 23/05/22. On behalf of NHS Greater Manchester Integrated Care (NHS GM), I would like to begin by offering our sincere condolences to Ms. Howards family for their loss.
Thank you for highlighting your concerns during Ms. Howards Inquest which concluded on 2 September
2022. On behalf of NHS GM, I apologise that you have had to bring these matters of concern to our attention but it is also very important to ensure we make the necessary improvements to the quality and safety of future services.
The inquest concluded that Violet’s death was as a consequence of natural causes. The medical cause of death was 1a) Sepsis; 1b) Hepatic abscess; 2) Extensive eczematised psoriasis, Psoriasis with arthropathy and Type 1 Diabetes Mellitus. Following the inquest, you raised concerns in your Regulation 28 Report to NHS GM that there is a risk future deaths will occur unless action is taken.
I hope the response below demonstrates to you and Ms. Howard’s family that NHS GM has taken the concerns you have raised seriously and 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 matter of concern that has been raised is in relation to ‘a gap in commissioning arrangements for dermatology services covering in-patients at the Royal Oldham Hospital. Those arrangements do not cover in-patients who are from outside of the Oldham area unless and until they become ‘emergency dermatological cases’ and meet the criteria for input from dermatology at Salford Royal Hospital’.
Dermatology specialist input for an inpatient within the Oldham Care Organisation, regardless of area of residence, is a provision within the block contract for services and therefore is an expected provision by the hospital. The Oldham hospital site has never directly provided dermatology services, and the Clinical Commissioning Group, now an NHS GM locality team, has on several occasions raised this with the care organisation as a concern and this has been amplified by the findings in this case. The proposed approach was a service level agreement (SLA) with Salford Royal NHS Foundation Trust (SRFT). This has been actioned by the Oldham Care Organisation Divisional Managing Director Medicine and is being monitored by the Oldham ICB Locality Team.
Regarding out-of-area cover, this should be provided via the block contract as described above. As a locality, services are commissioned from HCRG Care Group. HCRG are commissioned to deliver a community based secondary care dermatology service from the Integrated Care Centre. This service is an outpatient, diagnostic and 2 week-wait service which serves the registered population of Oldham hence the reason why the GP referral was declined and raises concern as to why this was the chosen route given the arrangements in place.
In relation to the second element of the concern:
“Those arrangements do not cover in-patients who are from outside of the Oldham area unless and until they become ‘emergency dermatological cases’ and meet the criteria for input from dermatology at Salford Royal Hospital. “
The service is not commissioned to supply in-reach services into the NCA, and therefore the Oldham Care Organisation are bound under the existing contract to provide the necessary service which should cover all levels of dermatology requirements for inpatients within the care organisation, not just those deemed to be dermatological emergencies.
I hope this helps explain that rather than a commissioning gap, this is a gap in acute provision. This is being addressed by the Care Organisation via the mechanism of an SLA. The Oldham locality team working with both Oldham Care Organisation and the wider NCA group continues to drive this issue forward and work with the organisation to complete their actions and gain assurances for the quality and safety of our patients.
Actions taken or being taken to share learning across Greater Manchester.
1. Learning to be presented/shared with the Greater Manchester System Quality Group. This meeting is attended by commissioners, including commissioners of specialist services, regulators, Healthwatch and NICE.
2. Shared learning from this and similar cases at Greater Manchester and borough level will be cascaded to professionals through relevant governance and learning forums.
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 Ms. Howards family that NHS GM has taken the concerns you have raised seriously and is committed to work 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 my attention and please do not hesitate to contact me should you need any further information.
Re: Regulation 28 Report to Prevent Future Deaths – Violet Elizabeth Howard 26/11/21
Thank you for your Regulation 28 Report dated 05/09/22 concerning the sad death of Violet Elizabeth Howard on 23/05/22. On behalf of NHS Greater Manchester Integrated Care (NHS GM), I would like to begin by offering our sincere condolences to Ms. Howards family for their loss.
Thank you for highlighting your concerns during Ms. Howards Inquest which concluded on 2 September
2022. On behalf of NHS GM, I apologise that you have had to bring these matters of concern to our attention but it is also very important to ensure we make the necessary improvements to the quality and safety of future services.
The inquest concluded that Violet’s death was as a consequence of natural causes. The medical cause of death was 1a) Sepsis; 1b) Hepatic abscess; 2) Extensive eczematised psoriasis, Psoriasis with arthropathy and Type 1 Diabetes Mellitus. Following the inquest, you raised concerns in your Regulation 28 Report to NHS GM that there is a risk future deaths will occur unless action is taken.
I hope the response below demonstrates to you and Ms. Howard’s family that NHS GM has taken the concerns you have raised seriously and 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 matter of concern that has been raised is in relation to ‘a gap in commissioning arrangements for dermatology services covering in-patients at the Royal Oldham Hospital. Those arrangements do not cover in-patients who are from outside of the Oldham area unless and until they become ‘emergency dermatological cases’ and meet the criteria for input from dermatology at Salford Royal Hospital’.
Dermatology specialist input for an inpatient within the Oldham Care Organisation, regardless of area of residence, is a provision within the block contract for services and therefore is an expected provision by the hospital. The Oldham hospital site has never directly provided dermatology services, and the Clinical Commissioning Group, now an NHS GM locality team, has on several occasions raised this with the care organisation as a concern and this has been amplified by the findings in this case. The proposed approach was a service level agreement (SLA) with Salford Royal NHS Foundation Trust (SRFT). This has been actioned by the Oldham Care Organisation Divisional Managing Director Medicine and is being monitored by the Oldham ICB Locality Team.
Regarding out-of-area cover, this should be provided via the block contract as described above. As a locality, services are commissioned from HCRG Care Group. HCRG are commissioned to deliver a community based secondary care dermatology service from the Integrated Care Centre. This service is an outpatient, diagnostic and 2 week-wait service which serves the registered population of Oldham hence the reason why the GP referral was declined and raises concern as to why this was the chosen route given the arrangements in place.
In relation to the second element of the concern:
“Those arrangements do not cover in-patients who are from outside of the Oldham area unless and until they become ‘emergency dermatological cases’ and meet the criteria for input from dermatology at Salford Royal Hospital. “
The service is not commissioned to supply in-reach services into the NCA, and therefore the Oldham Care Organisation are bound under the existing contract to provide the necessary service which should cover all levels of dermatology requirements for inpatients within the care organisation, not just those deemed to be dermatological emergencies.
I hope this helps explain that rather than a commissioning gap, this is a gap in acute provision. This is being addressed by the Care Organisation via the mechanism of an SLA. The Oldham locality team working with both Oldham Care Organisation and the wider NCA group continues to drive this issue forward and work with the organisation to complete their actions and gain assurances for the quality and safety of our patients.
Actions taken or being taken to share learning across Greater Manchester.
1. Learning to be presented/shared with the Greater Manchester System Quality Group. This meeting is attended by commissioners, including commissioners of specialist services, regulators, Healthwatch and NICE.
2. Shared learning from this and similar cases at Greater Manchester and borough level will be cascaded to professionals through relevant governance and learning forums.
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 Ms. Howards family that NHS GM has taken the concerns you have raised seriously and is committed to work 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 my attention and please do not hesitate to contact me should you need any further information.
Sent To
- NHS Greater Manchester Integrated Care
Response Status
Linked responses
1 of 1
56-Day Deadline
29 Nov 2022
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 23 May 2022 an investigation into the death of Violet Elizabeth Howard was commenced. The investigation concluded at the end of the inquest on 2 September 2022. I recorded a conclusion of Natural Causes. The medical cause of death was recorded as 1a) Sepsis 1 b) Hepatic abscess 2) Extensive eczematised psoriasis, Psoriasis with arthropathy and Type 1 Diabetes Mellitus
Circumstances of the Death
Ms Howard was admitted to Fairfield General Hospital on 13 March 2022 and diagnosed with sepsis caused by a hepatic abscess. She was transferred to the Royal Oldham Hospital (ROH) and underwent two procedures to drain the abscess. The abscess recurred and was not amenable to surgery because of its size and location. During the admission, Ms Howard developed a skin rash which required specialist dermatology input. From 22 April 2022, attempts were made by the treating team at the ROH to obtain dermatology input into Ms Howard's care. This involved enquiries with Manchester Royal Infirmary, Withington Hospital and Salford Royal Hospital (SRH). The outcome of those enquiries was that even though Ms Howard was an inpatient at the ROH, a referral to the dermatology service covering ROH had to be made through her GP. The referral from Ms Howard's GP was made and subsequently rejected on the basis that her postcode fell outside of the dermatology service's catchment area. By 27 April 2022, Ms Howard's skin condition was considered a dermatological emergency and as such she met the criteria for input from the dermatology team at SRH. I heard that the SRH dermatology clinic does not offer a service on 28 April and an appointment was made for Ms Howard to attend SRH on 29 April. Ms Howard was not able to attend this appointment as her condition deteriorated further on 28 April. A Consultant Dermatologist from SRH attended on Ms Howard at ROH on 1 May 2022 and diagnosed extensive eczematised psoriasis. This condition had impacted on Ms Howard's fluid balance, renal function and general reserves and is a contributory factor in her death. Whilst the evidence did not meet the required standard to show that earlier dermatology input would have averted Ms Howard's death, it would have mitigated the distress, discomfort and pain she experienced towards the end of her life. CORONE~SCONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: (1) There is a gap in the commissioning arrangements for dermatology services covering in-patients at the Royal Oldham Hospital. Those arrangements do not cover in-patients who are from outside of the Oldham area unless and until they become 'emergency dermatological cases' and meet the criteria for input from dermatology at Salford Royal Hospital.
Copies Sent To
Northern Care Alliance NHS Trust
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.