Dear Ms Mutch,

Re: Mr Alphonso Alexander Shearer

I write in response to the Prevention of Future Death (PFD) notice dated 28th April 2022 and respond accordingly to the matters raised in relation to the death of the late Mr Shearer. Firstly, on behalf of Trafford Clinical Commissioning Group (CCG), I would like to offer Mr Shearer’s family our sincerest condolences and we hope this response helps to answer any questions that remain outstanding for them.

You specifically asked us as a CCG to respond to section 5: Coroner’s Concerns, and we have been working with the GP’s and staff at North Trafford Group Practice (Mr Shearer’s GP practice) to investigate those concerns and gain an understanding of the learning so that we can share this with all our practices across Trafford.

The practice has provided a full and thorough response (attached to this response) to each of the points raised which include the practice level learning. Our response aims to enhance this further to offer assurance to you and Mr Shearer’s family that we have considered the action taken by the individual practice and we have shared this with all our practices in Trafford and encouraged them to implement the same systems to maximise the learning and in turn, help prevent any similar experiences for our patients and their families.

The CCG response to each of the concerns are provided below;

1. The inquest heard that Mr Shearer was frail and vulnerable with very poor swallow. When prescribing the clinicians did not recognise or have a system to flag up the need for liquid antibiotics rather than tablet antibiotics. This led to him not being able to commence antibiotics on the day he was identified as needing them. The inquest heard that it is important that in the community particularly for the vulnerable there is a system for recognising what form of antibiotics are most appropriate to prescribe to avoid delay.

Private & Confidential

F.A.O: Alison Mutch HM Senior Coroner

HM Coroner’s Court 1 Mount Tabor Street Stockport SK1 3AG

1st Floor Trafford Town Hall Talbot Road Stretford Manchester M32 0TH

Tel:

E-mail:

23rd June 2022

2

The practice has undertaken a review of the EMISWeb system which is used by all practices in Trafford, this is where all patient appointments and consultations are recorded. The system does allow for system warning alerts (often referred to by practice staff as “pop-ups”) when accessing a patient record to identify those who may need specific types of medication based around their personal needs, including swallowing difficulties. The practice is now in the process of identifying those patients who are coded with swallowing difficulties as well as those who are already receiving liquid medication, nutritional supplements or feeds. This will be carried out over the next 4 weeks and for each of those patients a “pop-up” up will be added to alert clinicians of the patient’s specific requirements. The practice Medicines Management Team are also supporting this work to help avoid any unnecessary delays in a patient’s medication. As a CCG we offer support with EMISWeb system to develop system alerts as well as other system capabilities and all our practices have had the training to be able to manage this system on a day to day basis. Whilst we are not responsible for the monitoring of the operational systems of our practices, we use our quarterly educational events which practice staff attend to share any changes to the system and share learning from events such as this. We are really pleased that the practice is undertaking this exercise to ensure patients with specific needs are managed appropriately.

2. The inquest heard that the AskmyGP system had been challenging for those involved with Mr Shearer and had made communication harder. The evidence identified that this was a particular issue for more vulnerable patients and their families
3. The inquest heard that he had not been seen face to face by a GP and that is meant that full extent of his deterioration was not recognised until he was seen by a paramedic from the practice who called an ambulance.

The adoption of AskmyGP during 2020 was planned as part of the NHS Long Term Plan to improve digital access for patients. This was expedited during the COVID-19 pandemic due to the advantages it offered in remote working. 70% of our practices in Trafford use this system which has enabled patients to access their practice without the need to physically attend on site which was encouraged during the pandemic where possible. The remaining 30% of our practices use similar digital systems with the same capabilities. These digital systems do not mean that that face to face appointments are not available. Each request on these systems are reviewed by a clinician and a decision is made on the method of consultation, which could be by telephone, email, video consultation, face to face or a home visit. Since the start of the pandemic all practices have been working in a challenging environment and had only seeing patients face to face where necessary, the digital system capabilities have helped to facilitate this and continues to be an effective way of managing patient

3

requests for treatment. Where patients are unable to access digital systems, practices should offer equitable alternative access to those patients such as phone calls in the case of Mr Shearer and those phone calls should be addressed effectively. As part of their review of the alert system on EMISWeb, North Trafford Group Practice are also placing alerts on the records of those patients who may struggle with digital access, this will include specific requirements such as the need for an interpreter, or additional support to undertake a consultation. We are pleased that the practice is monitoring the effectiveness of this system by discussing the learning from this event at their next Patient Participation Group, this group includes members from our local Healthwatch who act as advocates for our patient’s in Trafford. During May 2021 the CCG also undertook a review of the patient experience of AskmyGP and 90% of the patients who had used the system were highly satisfied with it. With this said we are also currently undertaking a piece of work to establish who is using the digital systems, and more importantly who isn’t? This will enable us to reduce the inequalities in digital access across the borough. We will ensure that any learning is shared with our practices as part of this work.

The AskmyGp system does allow for a request for a home visit and these are assessed by clinicians to determine the urgency. The clinician would usually make the initial contact by telephone to determine the history of the presenting condition and determine how best to arrange an assessment. In Mr Shearer’s case, I understand the family had difficulty arranging a home visit and the practice state that this was due to their request not being logged on the system on 17th August 2021 which was an error. They have reminded all reception staff of the importance of accurately recording all requests for home visits in the clinical system so that they are referred to clinicians for an assessment. This will be reinforced further during training sessions for reception staff. As I mentioned earlier the CCG is not responsible for the monitoring of how our practices operate their systems, however we are responsible for ensuring our GP practices are offering high quality care including equal access across the borough and support for those without digital access. This is something we will continue to monitor via our current Primary Care Health Inequalities Quality Aims plan. This plan has been in place since November 2020 and improving access to our GP practices is an ongoing theme within this.

This extremely sad case has highlighted a number of issues that can occur in healthcare systems and processes where a vulnerable patient may be at risk of a delay in treatment. This report gives us a real example to use in reminding all GPs in Trafford about those risks, what clinicians should be considering in terms of their own practice systems and the resources available to support clinicians in the management of vulnerable patients with complex needs. Over the next week, we will be sharing a copy of the Regulation 28 along with the responses to this in our “Practice Briefing”, an email update which is sent out to over 400 Primary Care staff in Trafford twice a week.

4

By way of further assurance, I am pleased to say that we currently have 27 practices in Trafford, 25 of those are rated as “Good” with the Care Quality Commission (CQC) and 2 are rated as “Outstanding”. The CQC process of monitoring and inspecting GP practices covers areas of person-centered care which takes into account the needs of different people and timely access to care and treatment. We don’t have any practices with any outstanding action plans or regulatory notices with CQC at this time, and all of our practices are subject to the current routine CQC monitoring process in place.

Our Quality Team meet regularly with our local CQC Inspector to discuss any areas of concern and where we can support our practices maintain high quality services. We also have an internal Quality Assurance Framework where we use data and soft intelligence to enable us to monitor elements of quality with our practices on a regular basis.

We hope our response is satisfactory for the issues raised, please do not hesitate to contact us should you require further clarification

Dr

Medical Director

Dear Ms Mutch, Re: Regulation 28 Report into the death of Alphonso Shearer We are grateful that you have shared with us the findings from your inquest and the matters of concern that you have raised. We would like to express our sincere condolences to the family for their loss and express our apologies for any distress caused to them during this difficult t ime. We have considered this matter and the issues raised in the Prevention of Future Deaths Report in great depth. Where relevant, we have made changes to our systems and processes within the North Trafford Group Practice in order to address the matters of concern raised. We have also reviewed, reinforced and will continue to educate staff about existing safety practices where this has been considered relevant to addressing the concerns. Our responses to each ofthe matters or concern are provided as follows. Concern 1: The inquest heard that MrShearer was frail and vulnerable with very poor swallow. When prescribing the clinicians did not recognise or have a system to flag up the need for liquid antibiotics rather than tablet antibiotics. This led to him not being able to commence antibiotics on the day he was identified as needing them. The inquest heard that it is important that in the community particularly for the vulnerable there is a system for recognising whatform ofantibiotics are most appropriate to prescribe to avoid delay. Page 1 of4

Response to Concern 1 Our clinical record system is called EMISWeb which is a system used by all practices in Trafford and many others across the UK. We record all patient appointments and consultations into this system. The system has the ability to add a pop-up warning alert when loading the patient record, and when changing between different views such as looking at the problem list or prescribing a medication. The Practice has now adopted the policy of adding alerts to all patients who could have difficulty swallowing medication. As part of implementing this system, we are currently in the process of identifying patients within our practice who meet the criteria to have this flag applied. We are searching our records to identify patients who have been coded with swallowing difficulties, as well as patients with indications of potential swallowing difficulties such as those already receiving liquid medication, nutritional supplements or feeds. We are aiming over the next 4 weeks to add a flag of 'Difficulty swallowing pills' where appropriate for these patients. The system will then allow us to search for patients with this code. Our medicines management team will add the alerts to the clinical system as well as to the screen message on the prescribing view for the patient. This will prompt clinicians when reviewing such patients or making changes to medication to make sure they prescribe medication that is suitable for the patient such as in soluble or liquid form if necessary. In addition to the above system changes, we have also discussed this matter as a learning event within the senior team at the practice, and will be disseminating the learning from this. We will also have a further discussion in our next clinical meeting so that the clinical staff are aware of the new flagging process and how to enter the clinical codes and alerts in the EMISWeb system. When a hospital letter comes through indicating any changes in the patient's ability to swallow, our workflow team will be trained to enter the codes and alerts as appropriate. Our medicines management team will be conducting searches on a monthly basis to ensure the appropriate alerts are in place. We will review this process after the first 3 months. If a patient finds they are unable to take a medication after it is dispensed, or the community pharmacist identifies that the patient is unable to take the medication, existing systems allow the patient or pharmacist to contact the surgery to request an alternative be delivered. The Practice is open until 18:30 hours for an alternative medication to be issued. If a patient requests medication that has been discussed at a previous consultation, a new consultation request is generated for the previous clinician to ensure continuity of care. However, if not available the request is passed to the on-call doctor who will then speak to the patient having reviewed the previous consultation. After 18:30 hours the call is directed to the NHS111 service to direct them to our out of hours medical services provider, Mastercall, who would consult with the patient and send a prescription for alternative medication to a pharmacy if required. Concern 2. The inquest heard that the ASK MY GP system had been challenging for those involved with Mr Shearer and had made communication harder. The evidence identified that this was a particular issue for more vulnerable patients and their families. Page 2 of4

Response to Concern 2 Following the NHS Long Term Plan to improve digital access for patients, a number of different digital solutions were considered. In 2019 North Trafford Group Practice, along with many others in Trafford, with support from the CCG, decided to use AskMyGP as a digital solution. The AskMyGP system was implemented in March 2020. It allows requests that come in from patients to be workflowed in the practice. Requests can be submitted in a variety of ways including online directly into the system, via telephone, or in person where a member of staff would enter it into the system on behalf of the caller or attending patient. All requests for consultations in AskMyGP are allocated to a clinician. Depending on the information provided, the clinician would contact the patient by telephone or by email, and if needed could arrange a video consultation, face to face consultation at the surgery, or a home visit if required. We have found that approximately 70% percent of our patients use the AskMyGP service themselves. One added benefit of allowing patients to make requests online is that it makes it easier for other patients who are unable to use the online system to contact the surgery by phone as there is a lower volume of calls. As mentioned earlier, the EMISWeb system allows us to put alerts on patients records to indicate when they are more vulnerable or ifthey struggle to use digital access. In response to the concern, we are in the process of putting these alerts in the system for relevant patients. We are hoping to complete this process over the next 4 weeks. This will help by alerting our staff that the patient may need extra support when requesting a consultation, or have specific requirements for the consultation such as an interpreter. This process has been discussed at practice meetings and is part of our call handling protocol. We have discussed patient access and the use of the AskMyGP system at our Patient Participation Group (PPG) meetings on several occasions. We have received good feedback overall about the system. However, we will also discuss the learnings from this recommendation at our next PPG meeting. One of our PPG members sits on Healthwatch Trafford, and one is a carer but registered at another practice. They both provide valuable insight into how they find using the AskMyGP system and we will take on board any further suggestions they may also have. Concern 3: The inquest heard that he had not been seen face to face by a GP and that meant that the full extent ofhis deterioration was not recognised until he was seen by a paramedic from the practice who called an ambulance Response to Concern 3 As mentioned earlier, we use EMISWeb as our clinical system and AskMyGP to help workflow the requests that come into the practice. As above, patients may input their requests directly into the AskMyGP system, or requests can be entered by staff for telephone or direct patient requests. The AskMyGp system allows an indication of whether the preferred response is email, telephone, video, a face-to-face consultation, or a home visit. All requests for a home visit are highlighted on the AskMyGP system. Visit requests are recorded on the clinical system and are initially assessed by a clinician to determine the urgency of the visit. They are given a high priority as a default. The allocated clinician may make initial contact by telephone to Page 3 of4

gather the history of the presenting condition, assess urgency, and to determine how best to arrange for any further assessment to take place. We also have an emergency call handling protocol in place for staffto be aware of any life-threatening symptoms which should not wait for a GP call-back, but be redirected to the 999 ambulance service. When the practice is closed from 18:30 to 08:00 and at weekends and bank holidays, out of hours medical cover is provided by Mastercall. Anyone that calls the practice at that time is redirected to the NHS 111 service. NHS 111 assess the request and direct the call to an appropriate service. If a GP was required out of hours, Mastercall would arrange a consultation or visit if required. We acknowledge the frustrations that the family of Mr Shearer experienced in trying to arrange a home visit. We have reviewed our systems to make sure they are appropriately robust with respect to recording and prioritising of requests for consultations and home visits. It appears in the case of Mr Shearer there was a failure to record the family's request in the system for a home visit on 17 August
2021. We have reminded all reception staff of the importance of properly recording all requests for home visits in the clinical system so they are referred to clinicians for assessment. This requirement will be reinforced by the office manager in orientation and training sessions for reception staff. We are currently looking at the feasibility of conducting a qualitative survey to investigate the experience of patients who have requested home visits. Once we have developed an appropriate questionnaire, our plan is to conduct this study over the next 3 to 6 months. With respect to the calling of 999 for an urgent ambulance for Mr Shearer, it has been reiterated to all clinical staff that upon calling 999, the clinician must remain with the patient until the arrival of the ambulance and until handed over to the first responder. We will continue to monitor the above actions in our regular practice meetings. Thank you again for pr:pviding us with your concerns. If any further information is required, please contact us on 0161 865 5556.

Dear Ms Mutch,

Re: Regulation 28 Report to Prevent Future Deaths – Alphonso Alexander Shearer 17/8/21

Thank you for sharing the Regulation 28 Report dated 28/4/22 concerning the sad death of Alphonso Alexander Shearer on 17/8/21. Firstly, I would like to express my deep condolences to Alphonso Alexander Shearer’s family.

The inquest concluded that Alphonso’s death was a result of 1a Urosepsis on a background of catheterisation; 1b Chronic Kidney Disease; II Oesophageal carcinoma, hypertension.

The Regulation 28 Report raises concerns that there is a risk future deaths will occur unless action is taken.

This letter addresses the issues that fall within the remit of Greater Manchester Health and Social Care Partnership (GMHSCP) and how we can share the learning from this case.

This matter has been reviewed by a Senior Primary Care Manager for GMHSCP with focus on the following points, raised by the Coroner:

1. The inquest heard that Mr Shearer was frail and vulnerable with very poor swallow. When prescribing the clinicians did not recognise or have a system to flag up the need for liquid antibiotics rather than tablet antibiotics. This led to him not being able to commence antibiotics on the day he was identified as needing them. The inquest heard that it is important that in the community

particularly for the vulnerable there is a system for recognising what form of antibiotics are most appropriate to prescribe to avoid delay.
2. The inquest heard that the ASK MY GP system had been challenging for those involved with Mr Shearer and had made communication harder. The evidence identified that this was a particular issue for more vulnerable patients and their families.
3. The inquest heard that he had not been seen face to face by a GP and that meant that the full extent of his deterioration was not recognised until he was seen by a paramedic from the practice who called an ambulance.

Response to the points raised by the Coroner: In Greater Manchester we strive to deliver the safest care for our patients, service users and families, and design the safest systems for our staff, and in doing this it is vital we are able to adapt to the evolving nature of the health and care system. Given the prominence of digital technologies, and their essential role in clinical care delivery, it is crucial that the patient record is maintained to support safety and reduce errors. It is also essential that digital innovation is delivered safely and does not lead to unintended harms. The potential for digital technologies to enhance safety in areas such as prescribing, record keeping, and data driven health and care is widely evidenced. However, we recognise that digital technologies without the appropriate mechanisms to indicate safety concerns ‘’ can have the potential to harm patients. The new National Patient Safety Strategy, focusing on digital technologies, and the national commitments and timescales it contains, will complement, and support the work currently underway in Greater Manchester as we collaborate across primary care and hospital services to reduce avoidable harm to patients. It is our commitment to:
• Improve the safety of digital technologies in health and care, now and in the future.
• Identify, and promote the use of, digital technologies as solutions to patient safety challenges.
• Develop new digital clinical safety training materials and expand access to training across the health and care workforce.
• Create a centralised source of digital clinical safety information, including optimised standards, guidelines, and best practice blueprints.

With regard to the specific matter of GP practices having a system to flag the need for liquid antibiotics rather than tablet antibiotics. Led by the regional chief pharmacist, NHS England has produced ‘An Interactive Guide To: Principles of Safe Medicine Administration in a Care Home Setting’ to be used across the region, and this includes principles for safeguarding individuals. These principles are also applicable for those living in their own home. We are aware that current workload pressures in general practice continue to be challenging, as practices are still coping with the additional demand and constraints of the pandemic. General practice continues to experience the release of pent-up demand, accumulated during the pandemic when people were less likely to consult their practice or seek

specialist care. Many practices are still catching up on the backlog of care for patients who have ongoing conditions. However, general practice remains resilient and last year, provided more appointments nationally for patients than in the equivalent period before the pandemic. Although it may not have appeared so in surgery waiting rooms, given social distancing requirements and the growth in telephone and online consultations, most general practice teams across Greater Manchester have never been busier. The majority of practices have been able to adapt and innovate during the pandemic, to maintain and improve access, including the use of remote appointments. At the same time, we know that patients’ access primary care has also not been as good as it should be. Some patients have experienced unacceptably poor access to general practice, including difficulty in contacting practices and seeing a GP, for a face- to-face appointment in particular. We acknowledge that those with the greatest health needs are sometimes also the most at risk of being left behind by the ability to access, manage and contribute to digital tools, information and services. We continue to work with our digital and GP service providers to ensure these technologies work for everyone, from the most digitally literate to the most technology averse, and that they reflect the needs of people trying to stay healthy, as well as those with complex conditions. Actions taken, or being taken, to prevent reoccurrence across Greater Manchester.
• In October 2021, NHS England set out a plan for improving access for patients and supporting general practice. This sets out how we will increase and optimise capacity, address variation, encourage good practice, and improve access, including face-to-face appointments with GPs.
• As part of this plan, general practice teams across Greater Manchester are now reviewing the balance for patients between remote and face-to-face consultations, as part of ongoing reflections on professional practice and surgery management arrangements.
• Greater Manchester integrated care system has completed an action plan with further steps to support improved access and address healthcare inequalities. The plan includes how each of our 10 local systems will tackle variation in general practice, which is our utmost priority. This will continue to be progressed following the establishment of NHS Greater Manchester Integrated Care and the closure of local clinical commissioning groups on 1 July:

(i) ensure all practices achieve at least pre-pandemic activity levels for the equivalent period (excluding COVID-19 vaccinations) (ii) increase overall appointment volumes in general practice and ensure appointment levels reflect the full deployment of additional roles in general practice (iii) increase the proportion of face-to-face appointments with GPs (iv) minimise 111 calls in-hours and avoidable A&E attendance that could otherwise be seen in general practice, and

(v) support all practices, to sign up to and make full use of general practice referrals to the community pharmacy consultation service for minor illnesses to divert demand and improve patient experience

• 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, local authority representatives and NICE.

Alongside this we are also working with the Care Quality Commission (CQC), which will work with NHS England to support systems in this process and to make the required improvements across those practices which are not meeting reasonable needs of patients. The CQC is rapidly developing an inspection methodology with a particular focus on access to GP services. To share the learning from this case we will also reiterate the importance of standardised and consistent recording of medication requirements on the patient record, and ensuring that protocols for prescribing, particularly when the patient has not been seen face-to-face by the practice, include a safety netting element. GMHSCP is committed to improving outcomes for the population of Greater Manchester. Key learning points and recommendations will be monitored to ensure they are embedded within practice.

I hope this response provides the relevant assurances you require. 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.