Dear Mr Morris

Re: Ms Michelle Jeffries

I write in response to the Regulation 28: Prevention of Future Death notice dated 22nd November 2021 and respond accordingly to the matters raised in relation to the death of the late Ms Michelle Jeffries. Firstly, on behalf of Trafford Clinical Commissioning Group (CCG), I would like to offer Ms Jeffries 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: Matters of Concern, and we would like to offer the following information which we hope is helpful.

1. The circumstances in which GP’s can safely oversee the prescription of multiple analgesics at high doses in the community, attempting to reduce reliance on such medication as indicated and;
2. When a referral to a pain specialist is mandated.

The CCG Medicines Optimisation team support prescribers with many aspects of prescribing including repeat prescribing to ensure robust and safe processes for managing patients repeat medication are in place. Included as part of this are systems for reviewing patients on “high risk” medication, which supports prescribers to ensure that patients on these medicines have regular medication reviews, including blood and physical healthcare monitoring.

In addition, the CCG Medicines Optimisation team have recently highlighted to practices that prescribing of analgesia is an area we could work collaboratively on to ensure that patients get the best outcomes from their treatment. Part of this would be to undertake a structured medication review with the patient, discussing their current treatment and the outcomes from them. With the patients agreement any treatments that the patient wasn’t benefitting from would be removed from their medication.

Private & Confidential

F.A.O: Christopher Morris HM Area Coroner for Manchester South HM Coroner’s Office The Coroner’s Court Mount Tabor Street Stockport SK1 3AG

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

Tel: 0161 912 4093 E-mail:

16th December 2021

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Depending on the type of medication, this may be done immediately or over a period of time, to ensure withdrawal from the medication did not happen.

Reducing overprescribing, including analgesia is part of the Department of Health and Social Care (DHSC) guidance; Good For You, Good For Us, Good for Everybody - A plan to reduce overprescribing to make patient care better and safer, support the NHS, and reduce carbon emissions.

All practices in Trafford now have a practice based pharmacist working with them and as part of their work they undertake structured medication reviews. The CCG Medicines Optimisation Team and practice based teams have been working together to prioritise patients requiring a medication review, with patients on high doses or multiple analgesia being highlighted.

Pain management and NICE guidance have previously been a topic at our local GP Education sessions, held quarterly. Please see documents attached below for further information on the Trafford CCG local guidance on Repeat Prescribing as well the National Institute for Clinical Excellence (NICE) guidance in relation to assessing and managing chronic pain in the over 16’s. The Repeat Prescribing guidance is currently under review and will be complete by 31st March 2022.

TCCG_Repeat_Prescri bing_Guidance_FINAL chronic-pain-primary
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In terms of when to refer patients to pain specialists, there isn’t a specific pain management pathway that offers GP’s guidance on when exactly to refer to a pain specialist. However, in Trafford, there is a commissioned Musculoskeletal (MSK) service available to patients as well as the Manchester Pain Service should any Trafford GP, based on their own clinical judgement, decide a referral is necessary.

• Trafford Community Musculoskeletal (MSK) Service. The MSK service provides treatments for adults (over 18) with Musculoskeletal (muscles, joints and bones) and orthopaedic conditions or injuries as well as chronic pain. The service offers multi-disciplinary care for patients experiencing persistent pain and mild to moderate distress. This involves Biopsychosocial assessment, individual treatment, Pain Management Programmes and medication advice. The team includes Clinical and Health Psychologists, Specialist Physiotherapists and Specialist Pain Nurses.

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• The Manchester Pain Service This is an integrated multidisciplinary pain service spanning the spectrum of acute and chronic pain. As well as helping to optimise pain relief during inpatient stays following surgical procedures or trauma, they also offer an outpatient service for pain which is more persistent or ‘chronic pain’. This is managed by a team of doctors, nurses, physiotherapists and psychologists and as a multidisciplinary team they aim to ease or reduce pain where possible, as well as offer support and guidance to help improve a patient’s quality of life.

This extremely sad case has highlighted a number of risks that can occur in healthcare where potent and high risk medicines are prescribed.

Fortunately the culture in pain management is changing with patients being offered non-pharmacological help and support, in preference, to manage their long term condition rather than medicines to try to “kill the pain”. 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 guidance and the resources available to support clinicians in the management of patients with chronic pain. We have therefore included this in our “Practice Briefing”; an email update which is sent out to over 400 Primary Care staff in Trafford twice a week. The information in the briefing also includes a link to the guidance documents we have shared with you above.

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 medicines management which include, prescribing of controlled drugs, medication reviews and systems for monitoring high risk medicines. 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

Medical Director

Gr e at er M a n c h e st er H e alt h a n d S o ci al C ar e P art n er s hi p 4t h Fl o or 3 Pi c c a dill y Pl a c e L o n d o n R o a d M a n c h e st er M 1 3 B N

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D e ar Mr M orri s

R e: R e g ul ati o n 2 8 R e p ort t o Pr e v e nt F ut ur e D e at h s – Mi c h ell e J effri e s 2 7/ 0 3/ 2 1

T h a n k y o u f or y o ur R e g ul ati o n 2 8 R e p ort d at e d 2 2/ 1 1/ 2 1 c o n c er ni n g t h e s a d d e at h of Mi c h ell e J effri e s o n 2 7/ 0 3/ 2 1 . Fir stl y, I w o ul d li k e t o e x pr e s s m y d e e p c o n d ol e n c e s t o Mi c h ell e J effri e s’ f a mil y.

T h e i n q u e st c o n cl u d e d t h at Mi c h ell e’ s d e at h w a s a r e s ult of t h e c o m bi n e d t o xi c eff e ct s of p ai n m e di c ati o n s .

F oll o wi n g t h e i n q u e st y o u r ai s e d c o n c er n s i n y o ur R e g ul ati o n 2 8 R e p ort t o Gr e at er M a n c h e st er H e alt h a n d S o ci al C ar e P art n er s hi p ( G M H S C P) t h at t h er e i s a ri s k f ut ur e d e at h s will o c c ur u nl e s s a cti o n i s t a k e n.

T hi s l ett er a d dr e s s e s t h e i s s u e s t h at f all wit hi n t h e r e mit of G M H S C P a n d h o w w e c a n s h ar e t h e l e ar ni n g fr o m t hi s c a s e .

P oi nt 1 – t h e cir c u m st a n c e s i n w hi c h G P’ s c a n s af el y o v er s e e t h e pr e s cri pti o n of m ulti pl e a n al e g e si c s i n hi g h d o s e s i n t h e c o m m u nit y, att e m pti n g t o r e d u c e r eli a n c e o n s u c h m e di c ati o n s a s i n di c at e d. T h e Tr aff or d C C G M e di ci n e s O pti mi s ati o n t e a m s u p p ort pr e s cri b er s wit h m a n y a s p e ct s of pr e s cri bi n g i n cl u di n g r e p e at pr e s cri bi n g t o e n s ur e r o b u st a n d s af e pr o c e s s e s f or m a n a gi n g p ati e nt s r e p e at m e di c ati o n ar e i n pl a c e. I n cl u d e d a s p art of t hi s ar e s y st e m s f or r e vi e wi n g p ati e nt s o n “ hi g h ri sk ” m e di c ati o n, w hi c h s u p p ort s pr e s cri b er s t o e n s ur e t h at p ati e nt s o n t h e s e m e di ci n e s h a v e r e g ul ar m e di c ati o n r e vi e w s, i n cl u di n g bl o o d a n d p h y si c al h e alt h c ar e m o nit ori n g. All pr a cti c e s i n Tr aff or d n o w h a v e a pr a cti c e b a s e d p h ar m a ci st w or ki n g wit h t h e m a n d a s p art of t h eir w or k t h e y u n d ert a k e str u ct ur e d m e di c ati o n r e vi e w s.

I n a d diti o n, t h e C C G M e di ci n e s O pti mi s ati o n t e a m h a v e r e c e ntl y hi g hli g ht e d t o pr a cti c e s t h at pr e s cri bi n g of a n al g e si a i s a n ar e a w e c o ul d w or k c oll a b or ati v el y o n t o e n s ur e t h at p ati e nt s g et t h e b e st o ut c o m e s fr o m t h eir tr e at m e nt. P art of t hi s w o ul d b e t o u n d ert a k e a str u ct ur e d m e di c ati o n r e vi e w wit h t h e p ati e nt, di s c u s si n g t h eir c urr e nt tre at m e nt a n d t h e o ut c o m e s fr o m t h e m. Wit h t h e p ati e nt s a gr e e m e nt a n y tr e at m e nt s t h at t h e p ati e nt w a s n’t be n efitti n g fr o m w o ul d b e r e m o v e d fr o m t h eir m e di c ati o n. D e p e n di n g o n t h e t y p e of m e di c ati o n, t hi s m a y b e d o n e i m m e di at el y or o v er a p er i o d of ti m e, t o e n s ur e a d v er s e si d e eff e ct s of wit h dr a w al fr o m t h e m e di c ati o n di d n ot h a p p e n.

R e d u ci n g o v er pr e s cri bi n g, i n cl u di n g a n al g e si a i s p art of t h e D e p art m e nt of H e alt h a n d S o ci al C ar e ( D H S C) g ui d a n c e; G o o d F or Y o u, G o o d F or U s, G o o d f or E v er y b o d y - A pl a n t o r e d u c e o v er p r e s cri bi n g t o m a k e p ati e nt c ar e b ett er a n d s af er, s u p p ort t h e N H S, a n d r e d u c e c ar b o n e mi s si o n s .

P ai n m a n a g e m e nt a n d NI C E g ui d a n c e h a v e pr e vi o u sl y b e e n di s c u s s e d at Tr aff or d l o c al G P E d u c ati o n s e s si o n s, h el d q u art erl y. Pl e a s e s e e d o c u m e nt s att a c h e d b el o w f or f urt h er i nf or m ati o n o n t h e Tr aff or d C C G l o c al g ui d a n c e o n R e p e at Pr e s cri bi n g a s w ell t h e N ati o n al I n stit ut e f or Cli ni c al E x c ell e n c e ( NI C E) g ui d a n c e i n r el ati o n t o a s s e s si n g a n d m a n a gi n g c hr o ni c p ai n i n t h e o v er 1 6’ s. T h e R e p e at Pr e s cri bi n g g ui d a n c e i s c urr e ntl y u n d er r e vi e w a n d will b e c o m pl et e b y 3 1 st M ar c h 2 0 2 2 .

T C C G_ R e p e at_ Pr es cri bi n g_ G ui d a n c e_ FI N A L

c hr o ni c- p ai n- pri m ar y
- a n d-s ec o n d ar y-i n- o v

P oi nt 2 - w h e n r ef err al t o a p ai n s p e ci a li st is m a n d at e d . I n t er m s of w h e n t o r ef er p ati e nt s t o p ai n s p e ci ali st s, t h er e i s n o s p e cifi c p ai n m a n a g e m e nt p at h w a y t h at off er s G P s g ui d a n c e o n w h e n e x a ctl y t o r ef er t o a p ai n s p e ci ali st. H o w e v er, i n Tr aff or d, t h er e i s a c o m mi s si o n e d M u s c ul o s k el et al ( M S K) s e r vi c e a v ail a bl e t o p ati e nt s a s w ell a s t h e M a n c h e st er P ai n S er vi c e s h o ul d a n y Tr aff or d G P, b a s e d o n t h eir o w n cli ni c al j u d g e m e nt, d e ci d e a r ef err al i s n e c e s s ar y.

T h e c ult ur e i n p ai n m a n a g e m e nt i s c h a n gi n g wit h p ati e nt s b ei n g off er e d n o n - p h ar m a c ol o gi c al h el p a n d s u p p ort, i n pr ef er e n c e, t o m a n a g e t h eir l o n g t er m c o n diti o n r at h er t h a n m e di ci n e s t o tr y t o “ kill t h e p ai n”. T hi s r e p ort gi v e s c oll e a g u e s a t a n gi bl e e x a m pl e t o u s e i n r e mi n di n g al l G P s i n Gr e at er M a n c h e st er a b o ut t h o s e ri s k s, w h at cli ni ci a n s s h o ul d b e c o n si d eri n g i n t er m s of g ui d a n c e a n d t h e r e s o ur c e s a v ail a bl e t o s u p p ort cli ni ci a n s i n t h e m a n a g e m e nt of p ati e nt s wit h c hr o ni c p ai n. A cti o n s t a k e n or b ei n g t a k e n t o pr e v e nt r e o c c urr e n c e a cr o s s Gr e at er M a n c h e st er.

1. L e ar ni n g t o b e pr e s e nt e d/ s h ar e d wit h t h e Gr e at er M a n c h e st er Q u alit y B o ar d. T hi s m e eti n g i s att e n d e d b y c o m mi s si o n er s, i n cl u di n g c o m mi s si o n er s of s p e ci ali st s er vi c e s, r e g ul at or s, H e alt h w at c h a n d NI C E .

2. C o m m u ni c ati o n t o all pr o vi d er s t o s h ar e a p pr o pri at e a d vi c e a n d g ui d a n c e a n d i ncr e a s e st aff a w ar e n e s s r e g ar di n g t h e r a n g e of m at eri al s t h at ar e alr e a d y a v ail a bl e.

3. S h ar e d l e ar ni n g fr o m t hi s a n d si mil ar c a s e s at Gr eat er M a n c h e st er a n d b or o u g h l e v el will b e c a s c a d e d t o pr of e s si o n al s t hr o u g h a p pr o pri at e g o v er n a n c e a n d l e ar ni n g f or u m s .

4. C C G s a cr o s s G r e at er M a n c h e st er will b e a s k e d t o pr o vi d e t hr o u g h Q u alit y B o ar d, a r e p ort o n h o w t h e y ar e re d u ci n g o v er pr e s cri bi n g, i n cl u di n g a n al g e si a a n d s u p p ort t h e i m pl e m e nt ati o n of “ D e p art m e nt of H e alt h a n d S o ci al C ar e ( D H S C) g ui d a n c e; G o o d F or Y o u, G o o d F or U s, G o o d f or E v er y b o d y - A pl a n to r e d u c e o v er pr e s cri bi n g t o m a k e p ati e nt c ar e b ett er a n d s af er, s u p p ort t h e N H S, a n d r e d u c e c ar b o n e mi s si o n s. ”

I n c o n cl u si o n, k e y l e ar ni n g p oi nt s a n d re c o m m e n d ati o n s will b e m o nit or e d t o e n s ur e t h e y ar e e m b e d d e d wit hi n pr a cti c e. G M H S C P i s c o m mitt e d t o i m pr o vi n g o ut c o m e s f or t h e p o p ul ati o n of Gr e at er M a n c h e st er.

I h o p e t hi s r e s p o n s e pr o vi d e s t h e r el e v a nt a s s ur a n c e s y o u r e q uir e. T h a n k y o u f or bri n gi n g t h e s e i m p ort a nt p ati e nt s af et y i s s u e s t o m y att e nti o n a n d pl e a s e d o n ot h e sit at e t o c o nt a ct m e s h o ul d y o u n e e d a n y f urt h er i nf or m ati o n.

Y o ur s s i n c er el y

C h ai r of G M M e di c al E x e c uti v e, G M H S C P