London's Regulatlon 28 Prevention ot Future to HM Senior Coroner for Inner North In response concerning Mr Macaulay Wilson Death (PFD) Report of 7 May 2021 North death of Mr Wilson, HM Senior Coroner for Inner Following the inquest touching on the was a5 a result of urosepsis secondary to a Fondom Mary Hassell, concluded that Mr Wilsor"s death it should have been changed every to change his indwelling catheter for almost a when and 1b long term indwelling failure of death was confirmed as Ia urosepsis 12 weeks. The medical cause catheter not changed since October 2019. the to Lower Clapton Group Practice on Concerns were raised within a 28 PFD report from the specialist team to the GP Conneranrccarcy with which mportadsnror mutiong teameefponsibe fofChe delivery Of the was then communicated to the district nursing team The Coroner noted in practice plan in relation to Mr Wilson"s indwelling cathetee . team'$ instructions proposed treatment when a GP conveved the specialist particular a loss of detail at the replaced the words catheter 'change'_ 2019,such that the words catheter 'care' of 18 February Dr behalf of Lower Clapton Group Practice; the practice parteeds Dr Mr Wilsonc The practice notes On condolences to the family and friends of like to express their deepest undertaken the following activities to seriousness of these events and in response has the recurrence: to ensure that when the practice receives Lower Clapton Group Practice has introduced a svstem members of the wider clinical team Correspondence containing instructions directed towaedsedehentiestrtetions will be clearly fovoevedin a patients care, such as district nursing the relevant _ referral to ensure there is highlighted tierapy ofehe original letter will accompany any onward patients who have We are undertaking an audit of all no loss of information or message clarity; that we clearly record in their notes how catheter products on their prescriptions We will ensure responsible for doing this We have frequently their catheter should be changed which servlce is the above data. This within our clinical system to aid us In capturing written an electronic template catheter to ensure we have accurate will be completed for all patients with a new indwelling the identity of the inforaatom in connection with catheter care, catheter change freatenwh patient Is identified as electronic alert which activates when a responsible team; We have written an This will prompt users to check beingin receipt of catheter products (from their prescription hicl) of the service holds patient's catheter was last changed and identify which part for when a responsibility for this all members of the team including the person responsible for We have communicated the above to have been incorporated into coding incoming patient related correspondence these processes team about this case to inductoon program We have informed our local medicines managementt can our within their monthly newsletter so that other practices ensure they can disseminate this risk incident via the Natlonal Reporting ensure a similar event does not occur: We have reported the wide EMIS have informed the CCG We are amending the City and Hackney Learning System housebound and vulnerable patients to include parameters template which is used when visiting increase risk such as catheters and catheter change as well as other issues which may such a5 pressure sores falls_ has also been be passed to the CQC, expanding on these activities report Practice is grateful for the opportunity the Regulation 28 report has proveided Lower Clapton Group these activities will not only reassure HM Senior to review strengthen our processes: We hope year; Regulation practice point Iwould Jand prevent = and and and and and and patient + and and =

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