t.!1lki .. Trafford Clinical Commissioning Group Private & Confidential F.A.O: Alison Mutch HM Senior Coroner Coroner's Court 1 Mount Tabor Street Stockport SK13AG 1st Floor Trafford Town Hall Talbot Road Stretford Manchester M32 0TH 28th July 2020 DearMs. Mutch1 Re: Mr George Tow~send, Case Number 313628 I write in response to your letter dated 4th June 2020, and respond accordingly to the matters raised in the corresponding Regulation 28 Report in relation to the death of the late Mr George Townsend. Firstly, on behalf of Trafford Clinical Commissioning Group (CCG), I would like to offer Mrs Townsend and her family our sincerest condolences and we hope this response helps to answer any questions that remain outstanding for her. Gloucester House Medical Centre has been under the caretaking arrangements of Firsway Health Centre in Sale, Trafford since 151 October 2019. This arrangement was due to the mutual termination of the contract between Dr-(MrTownsend's GP prior to his drath in August 2019) and Trafford CCG, thereforef in compiling this response we rave liaised with Dr IGP Partner fr9m Firsway Health Centre to gain access to the patient records and establish what has been put in place following the inquest to avoid any future reoccurrences ofthis nature with this practice. We have also considered any wider learning and support across the borough as part of this response. You specifically asked us as a CCG to respond to section 5: Matters of Concern, and we would like to offer the following information and context.
1. The Inquest heard that Mr Townsend should have been seen by a GP and had further tests prior to his admission to Salford Royal Hospital. The inquest heard that at the GP practice in question there were insufficient GP's to see patients. In addition there was no evidence of a clear escalation process from the Nurse to a Doctor within the Practice To help us to respond to these practice specific issues we have taken the opportunity to review the MrTownsend's patient records as well as the GP rota for the period when 1

,.,,:,1 Trafford , Clinical Commissioning Group the Advanced Nurse Practitioner (ANP) was involved in the management of his Gastro Oesophageal Reflux Disease which was from 241h June 2019. The table below shows the number of occasions he was assessed from 24th June 2019 up to 20th August 2019 and the GP availability at the practice at the time. Date Assessment GP availability in Practice Y/N and number fof GP's) 24/06/19 Telephone consultation with Yes-all day (1) ANP 03/07/19 Telephone consultation with No ANP 19/07/19 Telephone consultation with Yes (2) AM and (1) PM ANP 01/08/19 Telephone consultation with Yes AM (1) ANP
- 16/08/19 Telephone consultation with Yes All Day (1) ··­ ANP 20/08/19 Home visit undertaken by Yes All Day (2 - 1 am only) ANP Whilst there are general guiding principles and different methodologies for calculating the number of GPs to cover the number of patients a practice has, GP cover varies from practice to practice. The earlier diagnostic work found that the practice had slightly more GP appointments available to patients than average. Just prior to the 1st of August 2019 (251h Ju y 2019) the Practice Manager contacted the CCG to explain that the practice had clinical cover in place, but unfortunately after arranging Locum GP's they had failed to commence their agreed sessions. On these occasions the practice ensured that there was GP cover provided by the Out of Hours provider, Mastercall. This meant that whilst the ANP was the only clinician in the practice on some occasions, there was a GP available by phone for clinical advice. The information in the table above specifically identifies 3rd of July 2019 and the afternoon of 1st August 2019 as two dates where the ANP assessed the patient but there was no GP physically in practice at those times, with this said, should she have needed to escalate any clinical concerns this could have been done by contacting Mastercall over the phone. We are also aware that there were no GP's in practice on 13th and 14th August 2019 where the same support as above would have been available if required. 2

t.!1:ki Trafford Clinical Commissioning Group To offer further assurance around GP availability generally, the CCG has a Primary Care Workforce Delivery Group which has a remit to review current primary care workforce supply and demand in Trafford, and to make recommendations for improvement and sustainability, aligned to integrated commissioning principles. Some of its key actions include;
• To gather data on current local primary care workforce populations
• To identify areas that have the greatest need for a workforce model An example of an area of work undertaken by this group includes leading on the GM GP Retention Scheme which aims to facilitate initiatives to enable clinicians to stay in the workforce, through promoting new ways of working and providing a more flexible offer that will create·a sustainable model within general practice. The CCG is keen to attract, train and retain clinical roles and so part of Trafford's allocated funding for 2020/21 has been· used to secure placements on the Basic Trainer Course for 5 Trafford GPs, increasing the number of training environments within the borough. This initiative not only provides placements for training clinicians but also supports the professional development of our existing workforce.
2. The particular risks he presented with, his background health issues were not recognised when he showed signs of being unwell. To help the CCG to respond to this element, D for Clinical Quality, Trafford CCG, has liaised with Dr GP Partner at Firsway Health Centre the practice who are currently care taking Gloucester House Medical Centre. Dr- has also undertaken a review of ~r Townsend's medical records for the time period in question and we have been provided with some supporting information from Firsway (Appendix One), to help us understand further what learning has taken place to prevent any future deaths of this nature from this practice. Within the supporting information, the practice describes some of the systemic changes that were needed in light of the historical cultural issues within the practice. They have listed a number of key patient safety actions that have taken place since they took over Gloucester House Medical Practice, and this includes the following:­
• Robust clinical staffing arrangements with a mix of salaried and partner GP's
• Fortnightly clinical briefing sessions (daily since COVID-19)
• Robust process in place for any member of the nurse team to escalate issues to a GP if needed.
• New nurse working practices and protocols in place directed by Firsway's GP Nurse Lead/Partner
• Ongoing work to review and implement new practice policies and procedures 3

,~,:~1 Trafford Clinical Commissioning Group To offer some wider assurance around escalation and nursing support, the CCG confirms that all Practice Nurses in Trafford are given the opportunity to gain clinical supervision which is a formal systematic and continuous process of professional support and learning for practicing nurses. This is provided by the CCG Practice Nurse Development Lead, who is also a qualified practice nurse herself. This is a self-referral process which relies on the Practice Nurses contacting the Practice Nurse Development Lead directly and arranging a clinical supervision appointment. In the case of an Advanced Nurse Practitioner the expectation is that they would seek clinical supervision from any of the GP's in their practices.
3. The quality of the written medical notes at the GP practice was poor. Dr Prasad has undertaken a review of Mr medical records over the period in question and concludes that, although the note keeping could be better, there was sufficient documentation within the patient consultations to form a view. As well as this review, Dr- as also liaised with Dr- from Firsway who we understand was present at Mr Townsend's inquest and discussed documentation at the practice and the quality of the written medical notes. . . Dr - has advised that as part of the extensive work that was undertaken wheritneytook over the practice, a retrospective review of all patient clinical notes was undertaken. He explained that the issue around record keeping was that records , were poorly "read coded" which impacted on identifying background problems and recalls. Read Codes are a comprehensive list of clinical terms intended for use by healthcare professionals to describe the care and treatment given to patients. They include signs, sympto111s, treatments, investigations, occupations, diagnoses and drugs and appliances. Or - he has offered assurance that FirsWay have 1 spent a lot of time and res~ mmarise all patients notes registered with the practice to ensure they were as up to date as possible. We also understand that Firsway are hoping to make Gloucester House Medical Centre a training practice therefore they would need to ensure records are correct and kept up to date on an ongoing basis. The new systems and processes in place outlined in the supporting information (Appendix One) offers further assurance that there will be ongoing improvements at the practice to maintain quality of care, in particular around patient safety.
4. The inquest heard that there had been concerns locally within the area about the GP practice. They were now being acted upon by the CCG but the situation had been an issue for some time before there was intervention. 4

t~1:ki Trafford Clinical Commissioning Group In relation to Gloucester House Medical Practice specifically, please find below a timeline of events that occurred prior to the CQC inspection in August 2019. Gloucester House Medical Centre Timeline Summer2018 In the summer of 2018 the CCG became aware of concerns about the GP who ran 2 practices within the borough of Trafford. Old Trafford Medical Practice and Gloucester House Medical Centre. Primarily these concerns were related to the business side ofthe practice. Drlheld two different contracts a GMS contract (OTMP) and a PMS (GH) September 2018 Followin~meetings between Dr I and the CCG's Medical Director, Dr (MJ), agreed for the CCG to undertake a "practice diagnostic". The diagnostic took place on·the 25th & 26th September 2018. The report made 14 recommendations, which were mainly organisational issues. The report concluded that the clinical care was generally safe and this was based on triangulating a number of nationally available data sources. The report also noted that the practices were offering more appointments per 1000 population than the evidence suggested, however the report advised Dr I to appoint two additional full time GPs. Autumn 2018-Spring 2019 The diagnostic report was progressed with an ongoing action plan and overseen by the CCG Head Primary Care, and .who initially met weekly with

over time monthly. From the time of the diagnostic in September 2018 to May 2019 normal practice resumed. In January 2019 Dr successfully appointed a new practice manager who commence! employment atilie end of that month. I May 2019 The CCG became aware of staff raising more concerns about practice in May 2019, in particular in relation to the financial management of the practice and his commitment to the day to day running. In addition, this was at a time when Primary Care Networks were being established and had become the Clinical Director of the North Primary Care Clinical Network. As the practice issues became an escalating situation, the CCG requested a Quality summit with NHS England and the CQC, this is a review undertaken by a number of regulatory bodies to seek assurances around regulatory obligations. The practice was also part of the agenda's for the weekly Primary Care MDT meetings so updates were provided and discussed every week whilst concerns were being managed. July-August 2019 The Quality Summit took place on the 2nd July 2019 and the CQC Inspections took place on the 7th July 2019 (OTMP) and 7th August 2019(GH). As a result of the cac· 5

,~1:..j Trafford Clinical Commissioning Group inspections, Dr II; CQC registration was suspended from his Old Trafford contract meaning he would be unable to practice. In the case of GH his registration was not suspended meaning, whilst he could not practice he was still responsible for the day to day operational running of that practice, including the adequate clinical cover for patients 'registered at GH. The CCG were unable to intervene with recruiting with more GP's and other support generally as this was the responsibly of Dr that time. Between August and the 30th September 2019 Dr l had the right to appeal the CQC's decision to terminate his registration and duly started to do so, and whilst the CCG could not appoint a care taker nor formally intervene in the day to day running of the practice (this remained the responsibility of

the CCG did provide the usual general support which included engagement with the ANP directly to on a number of occasions for assurance around competence and that she would seek clinical supervision from the GP's in the practice if she felt unsure about any Issues. The CCG also provided additional Medicines Management support from the end of July to mid-September, primarily focusing on safety issues. This was over and above what a practice this size would normally receive (3 days a week as opposed to one). During the period between early July and September 2019 the CCG sought legal advice and in particular on the issuing of remedial notices and the termination of Dr contract. The contracts were mutually terminated on the 3Q1h September 2019 On 1st October 2019 Firsway Medical Centre formally took over the contract to care take Gloucester House Medical Centre and this contract is in place to this day and working well and engaging with the CCG on a regular basis in particular during the COVID-19 period. The CCG is working with NHSE to organise longer term plans for the fractice. To add some further assurance around how General Practice is monitored and regulated we have provided below some information to help understand how this works, this 1includes our local arrangements within Trafford CCG. British General Practice is regulated by the Regulation of General Practice Programme Board (RGPPB) which brings together the bodies responsible for the regulation and oversight of general practice in England. The board comprises of 11 separate regulators Including Care Quality Commission (CQC), NHS England and NHS Clinical Commissioners The CQC are responsible for the monitoring, inspection and regulation of services to make sure they meet fundamental standards of quality and safety and they publish that they find, including performance ratings to help people choose their care. GPs as contract holders are required to register with the CQC, typically these are the Partners 6

t.!11ki Trafford Clinical Commissioning Group of a practice and the CQC have the right to cancel a GP's/practices registration should they find any breaches in the fundamental standards. NHS England have two roles, one of which is, to hold a contract with GP practices but delegate the management of that contract to the relevant Clinical Commissioning Group (CCG). Their second role is to oversee the performance· of the practitioner. They investigate complaints and manage fitness to practice concerns, an example of which, might be if they were seen to be acting outside of General Medical Council (GMC) regulations Trafford CCG manages the contracts with GPs, there are three types of contracts, General Medical Services (GMS) which is a national contract, Personal Medical Services (PMS) which is a local contract, and only a medical practitioner can hold a GMS contract. The final primary care contract is an Alternative PMS (APMS) contract, which can be held by anyone, they are typically used for providers, such as Social Enterprises who provide services such as Out of Hours Services. These are time limited contracts The CCG is also responsible for the monitoring of quality of care provided for the healthcare services that it commissions. To support this there has been a Primary Care Quality Assurance and Improvement Framework (PCQAIF) in place since July
2019. The framework describes two approaches to support ongoing Improvements in quality in GP practices in Trafford. Please note that, at this time out of the 30 GP practices across the borough," 2 are "Outstanding" (7%), 28 {93%) are rated as "Good with the Care Quality Commission (CQC). The CCG engages with the Trafford CQC Inspector on a regular basis (curr~ntly weekly) to gain updates on each other's work pr9grammes/visits which help inform any practice specific engagement and progress of improvement work. Within the (PCQAIF) there are two approaches to quality improvement: Reactive If a practice has a poor CQC outcome or if issues are identified that require immediate intervention, this is discussed at the weekly multidisciplinary team meeting (MDT) and actions agreed. Weekly Core MDT Membership
• Clinical Director of Quality
• Medical Director
• Commissioner
• Safeguarding/Nursing Representative 7

,~1:~1 Trafford . Clinical Commissioning Group
• Performance and Quality Improvement Representative
• Medicines Optimisation Representative There could be occasions where subject matter experts will be required to attend the MDT, these include colleagues from Business Intelligence, Infection Control or Information Governance. There are key actions from the MDT and discussions include, levels of risk, engagement with the practice, development of action plans, and escalation to relevant senior committees eg: Senior Leader Team meeting at the CCG. Proactive This is the routine monitoring of practice profiles, these are individual profiles set up in the CCG intelligence system "Tableau" which is the data system that holds a wide range of primary care data, a sub-set of Indicators has been determined to create a surveillance dash board which acts as an Early Warning System (EWS) which indicates key areas to focus on to improve. The EWS has been developed to bring together a range of available routine data sources to identify those practices where there is significant variation from the expected values. Data includes, secondary care, prescribing, progress of diabetes 8 care process, QOF, list size changes and patient GP surveys. Those practices with the highest number of metrics showing significant variation are flagged for further analysis and discussion at the monthly Primary Care Quality Assurance group (PCQAG), and whilst the data allows some indication where support may be needed, this is not solely relied on. Soft intelligence is also gained from the PCQAG members prior to any engagement with a practice and this includes areas such as prescribing, safeguarding, and complaints. I Engaging with Practices Up to mid-March 2020 the Quality Team which includes the CCG Associate Clinical Director for Quality and the Performance and Quality Improvement Manager were working to a 2020 schedule of Quality Visits with all 30 practices in Trafford which were prioritised around the top outlying practices in the (EWS) as well as those practices who required additional support around resilience eg: single handed practices. This approach was working well to build strong relationships with our primary care colleagues and discuss their challenges with us earlier on so that we could offer support where we could to maintain good quality services. The intention was that all practices would have an onsite quality visit during 2020. As part of this work we are able to offer guidance on some external support options on offer to practices and this was offered where appropriate including Local Medical 8

,~,:~1 Trafford Clinical Commissioning Group Committee (LMC) and The Greater Manchester GP Excellence Programme which offers training opportunities to practice staff. The COVID19 pandemic has meant that we have had to pause some of our quality work including the proactive practice visits while there have been focused work with our practices to support them during the pandemic in prioritising and remodeling services to ensure patients are treated at the right time in-the right place. Now that we are moving into the next phase of COVID planning we will be working with our colleagues in the CCG to develop the framework further following the pandemic so that it. is fit for purpose and continues to offer support to practices in a collaborative way whilst maintaining a level ofassurance around key aspects of quality including CQC standards and National and Greater Manchester performance measures. Reporting and Accountability The Primary Care Quality Assurance Group (PCQAG) The Primary Care Quality Assurance Group (PCQAG) is a fundamental part of the Primary Care Quality, Assurance and Improvement Framework and all updates, themes and trends from quality visits are reported there. The group seeks recommendations on appropriate actions to take relating to the practices identified via the Tableau Data Surveillance Group and other sources of quality intelligence· including Medicines Management, Safeguarding and Infection Control colleagues. Considerations are also discussed around future working alongside Primary Care Networks to improve quality at Network level. TCCG Primary Care Commissioning Committee (PCCC), Quality, Finance and Performance Committee (QFP) and Governing Body.
-Summary reports are presented to the QFP Committee and the PCCC by exception where there are specific areas ofgood practice to share, or where concerns have been raised. The committees are asked for approval on suggested actions· put forward to support practices to improve. Deep dive analysis reports are also provided at the request of the committee as required, and a "Lessons Learned Report" in relation to Gloucester House Medical Centre was tabled at PCCC in February 2020. As sub-committees of TCCG Governing Body, escalation is decided on a case by case basis, usually by exception. 9

,~1:41 Trafford Clinical Commissioning Group We hope our response is satisfactory for the issues raised, please do not hesitate to contact us should you require further clarification Dr- Me~ r .__ 10