Dear Ms Saunders I am writing to you in response to the Regulation 28 report you sent me regarding the death of Mr Brian Wareham dated 14th January 2022. As section (6) — "Action should be taken", I can confirm that this matter has been investigated within the practice. In addition, following a meeting between Dr

and representatives of the Health Board on 2nd February 2022, we ~.;nderstand a further process is continuing within the Health Board, with which we are cooperating fully. As part of this process we have fully explored all current options and opportunities for communication between Primary and Secondary Care and have ensured that all clinical staff are aware of them. In particular we have explored specific obstacles to communication within this case and addressed them. We understand that there is an ongoing programme within the Health Board to further facilitate communication between primary and Secondary Care and we are engaging positively with that work. I hope this response provides you with the information requested.

Dear Ms Saunders Re: Aneurin Bevan University Hea.Ith.Board response to Regulation 28 Report received following the inquest touching on the death of Mr Brian Wareham. Thank you for your report dated 14 January 2022, which was received by the Health Board on 19 January 2022. We have conducted a review of this case, which has included a review of Primary and Secondary Care clinical records. This response is based on information from this review, provided by Dr

, Primary Care Clinical Director. Further to your report, the information presented below is intended to describe the action taken/being taken by the Aneurin Bevan University Health Board (ABUHB) to mitigate the risk of future deaths. Mr Wareham's case, as is illustrated by the statements provided to yourself prior to the inquest, was complex and required involvement of multiple professionals. In addition to this he had two significant medical conditions (oesophageal dysmotility and small cell cancer of the lung) which were difficult to diagnose and where the treatment options were limited. Specifically, there were no curative treatment options that were deemed suitable by the treating specialists. The experience of Mr Wareham and his family demonstrates the challenges and difficulties of coordinating care between different Specialist teams, Hospital sites and Care settings. Pencadlys Headquarters Ysbyty Sant Cadog St Cadoc's Hospital Ffordd Y Lodj Lodge Road Caerllion Caerleon Casnewydd Newport De Cymru NP18 3XQ South Wales NP18 3XQ

Bwrdd lechyd Prifysgol Aneurin Bevan yw enw gweithredol Bwrdd lechyd Prifysgol Aneurin Bevan Aneurin Bevan University Health Board is the operational name of Aneurin Bevan University Health Board

Ms Caroline Saunders 2 21 February 2022 Such situations can be particularly challenging for Primary Care, as highlighted by Dr during his evidence. Dr J has discussed Mr Wareham's care with Dr and the concerns that this case highlighted. With the benefit of access to the full medical records, it was apparent that the Gastroenterologist, Dr , had contacted Dr by email to give a detailed summary of Mr Wareham's swallowing issues and the plan of care. This email was included in the main GP clinical record. Also, a detailed letter regarding the diagnosis of small cell cancer and the management plan was sent to the Practice by Dr

. This included the names of key worker contacts (Lung Cancer Specialist Nurses), which is a Welsh Government recommendation for all individuals who are diagnosed with cancer. Mr Wareham remained under the care of Dietitians and regular written updates and prescription recommendations were sent to the Practice. He was also referred to Speech and Language Therapy by the GP Practice. For individuals in the community, the registered GP has overall responsibility for their medical care. The Primary Care team will therefore be the first point of contact for most health issues, and will take the role of coordinators in a patient's health care management. However, we acknowledge that in these situations it can be difficult for Primary Care teams to ascertain who is the most appropriate single point of contact when needing support to care for individuals who have multiple complex health issues. Due to specialisation in hospital medicine, there may not be a single point of contact which requires Primary Care teams to be a point of continuity and coordination. There are multiple ways in which Primary Care teams can obtain information regarding an individual's hospital care. In the Gwent area, GPs have access to the Clinical Workstation (CWS) system where all clinic letters and hospital records are stored. This enables a GP to review records and past/future appointments to ascertain which hospital clinicians are involved in an individual's care. Clinic and Discharge letters would usually also be sent directly to a GP Practice, which will include the name of the responsible consultant and contact details for the secretary. Contact details for hospital based clinicians can be obtained through hospital telephony switchboards or via the NHS email address book, which is available to GPs. These sources of information and support would have been available to Dr when delivering care to Mr Wareham. Mr Wareham's GP Practice received communication from Gastroenterology, Respiratory Medicine, Dietitians, Speech and Language Therapy, and Cancer Nurse Specialists. It is apparent from the GP clinical records that once Mr Wareham was referred to St David's Foundation Community team, the Palliative Care Nurse fulfilled the role of care coordinator in the community and single point of contact. On discussing the issues of communication with Secondary Care with Dr , he pinpoints telephone communication as a key method which is often helpful but rarely possible in practice, whilst acknowledging that it is very difficult for hospital specialists to contact GPs by telephone in a timely manner.

Ms Caroline Saunders 3 21 February 2022 Due to work patterns and pressures of work, which would have been a particular issue in 2020 during the early stages of the Covid 19 pandemic, synchronous communication between Primary Care and hospital specialists (eg by telephone) is difficult to facilitate. Dr D expressed the view that he did not seek further direct advice from hospital specialists regarding Mr Wareham following his admission in June 2020, as it appeared evident from the hospital records that they did not feel further specialist interventions were appropriate or possible. However, we note that Mr Wareham continued to have follow up with the Dietitian and the Lung Cancer CNS and the Practice referred him for assessment with Speech and Language Therapy. The outcomes of these reviews were communicated to the GP Practice. Since 2020, major changes have taken place within ABUHB boundary due to Covid 19, but also due to the reorganisation of our Services and the opening of the Grange University Hospital. These changes have required us to develop methods and strategies to enhance communication at the interface between Primary and Secondary care. Some of the main changes we have made include:
• Establishment of a single point of access Flow Centre for urgent referrals for admission.
• The Flow Centre line includes the option to speak to a Medical Consultant for clinical advice.
• Launch of direct access telephone advice lines for urgent and outpatient queries using the "Consultant Connect" advice and guidance app.
• A directory of "bypass numbers" to allow hospital teams to contact GP surgeries directly when there is an immediate need. As you will be aware, the Medical Examiner (ME) Service is now operating in Gwent with cases referred by the ME being reviewed by a Multidisciplinary Panel, which includes Primary Care input. This provides us with a further mechanism to identify and review any issues regarding the interface between Primary and Secondary care. We also send all GPs a weekly message from the Deputy Medical Director, highlighting key information and any changes to Secondary Care Services to ensure Primary Care remain up to date on how to access and communicate with Specialist Services. Information on pathways, Secondary Care Services and advice lines is also obtainable on the ABUHB intranet, which is accessible to GPs through the NHS computer network. As part of our urgent care and outpatient transformation work streams, we aim to keep these resources up to date as Services evolve.

Ms Caroline Saunders 4 21 February 2022 I trust that this information addresses the concerns raised in your report, however please do not hesitate to contact me should you require any further information.