Dear Miss Serrano

Re: Regulation 28 Report to Prevent Future Deaths – Mrs Christine Forbes

Thank you for your Regulation 28 Report dated 23 September 2020 concerning the death of Mrs Christine Forbes on the 2 February 2020. Firstly, I would like to express my deep condolences to Mrs Forbes family.

The regulation 28 report concludes Mrs Forbes death was a result of Combined Oxycodone and Zolpidem Toxicity; and Coronary Artery Atherosclerosis

Following the inquest you raised concerns in your Regulation 28 to NHS Derby and Derbyshire Clinical Commissioning Group –

That when patients register at GP surgeries (across England) they do so without their medical notes and history. This material can take a significant amount of time to be sent to a GP practice after a request is sent to Primary Care Support England. Doctors and other medical practitioners are therefore treating and prescribing in situations where a full medical history is not known.

In response to the concerns raised:

All general practices across Derby and Derbyshire are enabled for GP2GP electronic record transfer; this is an electronic system which allows patients' electronic health records to be transferred between their old and new practices within a matter of minutes (at most 24hrs) , when a patient registers with a new GP Practice.

Chair:

Chief Executive Officer:

Head office address: 1st Floor North, Cardinal Square, 10 Nottingham Road, Derby, DE1 3QT

The aim of GP2GP is to:

• Improve patient care by making full and detailed medical records available to the patient’s new practice to support first and later consultations.

• Prevents the need for a patient to provide their past medical history as this is already visible to the clinician seeing the patient.

• Supports safer prescribing provided through access to the patient's current and past medication and to any recorded allergies and adverse reactions and repeat medication details will be available for the patient's first medication review with the new GP

Where GP2GP electronic record fails this is usually due to the sending (previous practice) not being enabled, the record is too large (very rare) or the patient has transferred from outside of England. In these events the receiving practice should contact the sending practice and request a full patient print-out whilst awaiting the record through Primary Care Services England.

In response to the Regulation 28 concern NHS Derby and Derbyshire Clinical Commissioning Group have liaised with Ashbourne Medical Practice to support a comprehensive reply. We shared the concern raised by the coroner and the practice has undertaken further investigation into the GP2GP electronic record transfer.

In summary the practice actioned the GP2GP electronic record transfer on the date that Mrs Forbes registered at the practice on the 28.11.2019

SystmOne are not able to show what Mrs Forbes record may have looked like on a particular date, but they confirmed that when the GP2GP transfer task was actioned (on 28/11/2019) all previous electronic data including correspondence should have been integrated into the record.

The practice process at the time of Mrs Forbes registration was that new patient records were summarised by administrative staff once the paper notes arrived, and as part of this process both the paper notes and the electronic record were reviewed.

The paper notes were received at the practice on 14th January 2020 (7 weeks after registration - usual timeframe), however administrative staff did not summarise them in this case before Mrs Forbes death (which occurred within 3 weeks of receipt of the paper notes).

The practice has put a new process in place where any electronic records dated in the last 3 months are reviewed by administrative staff for any urgent safeguarding events / suicide etc. This would prompt administrative staff to prioritise those records for summarising once arrived and alert the responsible GP. The practice also looked at the pharmacist’s consultation on 11/12/2019. The pharmacist linked the 'medication review done' code to 2x problems which were recorded in 2016 and 2017 - this would suggest that he was able to see information previously recorded. His consultation was recorded contemporaneously.

Derby and Derbyshire CCG commission the North of England Commissioning Support Unit to support GP Primary Care Informatics; this includes modular training over a range of subjects including GP2GP Electronic Record Transfer and Note Summarisation.

In response to the raised concern Derby and Derbyshire CCG will:

Chair:

Chief Executive Officer:

Head office address: 1st Floor North, Cardinal Square, 10 Nottingham Road, Derby, DE1 3QT

• Offer additional GP2GP/ Record Transfer training to Ashbourne Medical Practice
• Offer additional training Note Summarisation to Ashbourne Medical Practice
• Circulate information about available GP2GP and Note Summarisation training to all practices.
• Include information about GP2GP and Note Summarisation training into the GP Membership Bulletin
• Include overview of available training within DDCCG Clinical Governance leads meetings

Thank you for bringing these important patient safety issue to my attention and please do not hesitate to contact me should you need any further information.