Dear Ms Kearsley

Re: Ms Beverley Shaw

Further to your Regulation 28 report of 10th June 2019 following the inquest into the death of Ms Shaw, we can confirm that a full investigation into the matters raised regarding the care received by Ms Shaw has been undertaken and we are now in a position to respond to the concerns raised. The matters of concern raised and the actions we will take as a CCG to address these concerns are as follows:

1. There was a lack of communication between Turning point and the GP Practice specifically in respect of Ms Shaw’s use of butane gas.

2. There is no record of a response from the GP practice to Turning point following their letter dated the 15th May 2018.

3. A medication review took place in the GP Practice in August 2018…there is no evidence that there was a full review of all medications prescribed to Ms Shaw.

4. The Court heard evidence that following the transition from another provider to Turning Point, a decision was taken that all medical records do not need to be carried over to Turning Point…hence they do not have the full past medical history available.

The review of the timeline of events with the practice has demonstrated where gaps in communication have had an impact. The practice acknowledges the fact that the reference to butane gas within the illicit drugs section of the letter may have been missed by doctors and Turning Point have also highlighted the need to be explicit about substance use in addition to prescribed medications, with both agencies acknowledging that this detail could be improved by both parties to ensure recognition of the impact on the individual concerned and therefore appropriate treatment and management from a prescribing perspective.

In respect of the butane gas use, the appropriate electronic code has been identified to flag misuse of butane on the EMIS system. This will be communicated to all practices as part of the lessons learned from this review to ensure that all Oldham GP practices are aware of this code.

The CCG is also keen to involve colleagues in our Local Authority Trading Standards department to look into the supply of the butane gas in this lady’s local area. As we embrace a place based method of working it is vitally important that we are looking at all influencing factors and the potential sale of large quantities of gas needs further scrutiny.

The events surrounding Ms Shaw’s death highlight the requirement for effective and up to date ‘Did Not Attend’ policies to be followed in Primary Care and to initiate discussion in practice meetings to ensure holistic information is shared and reviewed by the team in a manner which supports clinicians to make decisions based on the full facts and influencing factors. Such discussions can trigger communication back to secondary providers such as Turning Point to clarify and/or share information. The presence of Focussed Care within a number of Oldham practices has been seen to support such instances where substance use influences existing co-morbidities and as a CCG we are promoting wider uptake of this across the Oldham footprint. Practices that do not have a focussed Care worker directly linked to their practice do have access through the central office and this will be re-communicated as part of the lessons learned from this situation.

From a system perspective, there is clear learning in reviewing the medication and prescribing issues identified in Ms Shaw’s situation. This has highlighted some locum GP competency issues within the practice that have been addressed through the appropriate channels. The learning that has arisen from reviewing this lady’s care as a significant event has emphasised the importance of careful consideration of methadone use and subsequent or potential prescribed medication interactions. There is the facility for medications prescribed external to the practice (i.e. hospital or externally commissioned service such as Turning Point) to be entered into the EMIS system and therefore prompt alerts. This will also be highlighted to all practices and supported through the clinical pharmacy in-reach into all clusters.

Oldham CCG has a number of Clinical Pharmacists who work at Cluster level to support practices, carry out audit work and deliver CCG commissioned pieces of work. It is not within the current resource for these individuals to carry out reconciliations for every patient within every practice, therefore the role of the Clinical Pharmacist would not necessarily have picked this issue up. The CCG believes that the focus on entering externally prescribed medications onto the system as described in the paragraph above is a safer way of improving alerts & visibility of such interactions.

The CCG are co-ordinating a learning event with Hopwood House Medical Centre and the Oldham Turning Point team to facilitate a group reflection and agreed actions on how we can improve working relationships. The learning from this will also form the basis of a learning event that Turning Point are undertaking across the borough with those GP practices signed up to shared care arrangements.

We hope that this demonstrates that the CCG has robustly reviewed all aspects of the concerns raised within the Regulation 28 notice and provides assurances regarding the lessons learned and the actions taken to prevent reoccurrence in the future.

Please do not hesitate to contact either one of us should you wish to discuss and further concern.

Kind Regards

ith

Dear Ms Kearsley,  We were disappointed to receive the regulation 28 report from you dated 10th June, 2019.  At Turning Point we pride ourselves on providing safe and well governed services and our key  regulator, the Care Quality Commission, has rated us as Good or Outstanding in all our community  substance misuse services. The foundation of this high quality and governance is based on a learning  culture and continual improvement.  Whilst we recognise that the clinician had written to the GP, we accept that there is more that we  could do to improve this communication, not only in this tragic case but also more broadly across  our substance misuse services. Therefore, we have undertaken a wide ranging review of GP  communication across all our community substance misuse services, not just in Rochdale and  Oldham. That review has been led by our Senior Management Team, including our senior clinical  team, and our Risk and Assurance department.  This review has highlighted the key processes that we needed to change in order to improve  effective communication and reduce the risk of future recurrence. Those processes are the template  used by prescribers to review clients, the frequency of communication with GPs, the way that  communication is recorded on our electronic client records system and the processes for audit of  the frequency of that communication.  We also reviewed our systems for following up requests to GPs for information and the way in which  we transfer client data at the beginning and at the end of contracts.  The results of those reviews are captured in the attached action plan.  I am pleased to say that we have made all those improvements not only in Rochdale and Oldham but  also in all our community substance misuse services across the country and made the changes within  our planned timescales. We have also agreed how we will monitor compliance with those new  standards as part of our routine management audits. 

We believe that these changes will ensure that we are able to prevent recurrences of the issues you  have raised with us in your regulation 28 report.  We are aware that a copy of this response may be sent to the family of Ms Shaw and on behalf of  the staff team and the organisation I wish to offer our sincere condolences to them for the sad loss  of their loved one.   Should you wish me to clarify any of the action plan or the points above, please do not hesitate to  contact me.

Dear Ms Kearsley, Re; Report to prevent future deaths following the inquest of SHAW_Beverley (Miss) Further to your Regulation 28: Report letter to prevent future deaths and the inquest for Miss Beverley Shaw, Hopwood House Medical Practice have reflected on the learnings from the inquest and looked further into the electronic records of the deceased patient: I will answer the concerns in the order addressed by the court Communication Since the inquest we have as a practice reflected on Beverley's death and have discussed what we could have done differently to prevent her death: We noticed that in her records she had many failed appointments (DNAs) and possibly not fully engaged with clinicians about her health: In April 2019 we put together a DNA policy The policy outlines that patients who DNA shall be discussed in the practice meeting and a suitable method of contacting the patient should be sought: On reflection with this patient if we had done Miss Shaw could have been referred onto the Focus Care worker linked to our practice and she would have had a home visit assessment. From this we may have been made aware of the extent of her Butane abuse and this could have been communicated to the clinicians and Turning Point: 2019 Way this,`

From the practice team meeting and reviewing her medical records, not much was known about her butane abuse. As you have highlighted, only one document from the 15th 20/18 simply recorded Use of cans of butane daily' There was no further information given on this. This was written under the section of illicit and I feel that on reading this document that it is possible that this statement could have been missed by the GPs when It may be also to have been overlooked by the practice as the letter was from a commissioned addiction service, that the Butane addiction was dealt with. However on our behalf perhaps, we could have prompted for more information regarding this On speaking to a worker (that works for Turning Point), attached to our practice, regarding the recreational use of Butane. He was surprised to hear of the volume that she was He was not aware of assessing any patient who had used Butane to the extent that Miss Shaw had and he would feed back our concerns to his colleagues. We also found the electronic code 'Misuse of Butane EMISNQMI97 . That we will use in future to code this on the Problem List_ Regarding our communication with Turning Point, we responded to their letter on the 15th May 2018 by emailing the information requested: asked for recent blood tests results, and a copy ofher summary. This included her past medical history and current medication_ A task was sent to reception promptly by the GP, on the letter to send the requested documentation: The audit evidence for this is as attached_ Medication Review The last medication review was done by one of our regular locum doctors who has been working at the practice for the last 3 years From the practice meeting we concluded that the medication review was sub-adequate and the lead GP of the practice will feed this back to him: However; given the time limits and pressures in primary care, and the inconsistencies of CCG employed pharmacists, the practice has made a decision to employ clinical pharmacist do complicated medication reviews and with the workload. Despite this, as highlighted already by the letter from the 1sth 2018 sent byi Consultant Psychiatrist); have a clear accurate record of Miss Shaw $ medication and any interactions that may have been overlooked by the practice, perhaps should have been double checked then Looking at the electronic records, and using the Safety check tool, there are; "no high severity warnings" or contra-indications with the medications There is a "medium severity warning" regarding use of Methadone and Acute Hepatic failure, suggesting avoid or a reduced dose is used. Again, there was a "medium severity warning" regarding the concurrent use of Methadone with Olanzapine Tablets, Amitriptyline, Promazine and Pregabalin causing a prolonged QT interval. The manufacturers advice was to avoid use with 2 Or more associated with QT prolongation: Had methadone been added to the medication list, this perhaps would have been avoided May drugs coding: drugs using: They reading help - May ' they drug Smg drugs

This patient was under Pennine MSK persistent pain service
3. Miss Shaw was suffering from Psychological distress in the context of Trigeminal neuralgia and had a history of Ekbom syndrome_ In the last clinic letter from the service dated the 3rd August 2018, had advised to reduce the Olanzapine to 12_ per day in 2 divided doses, then after a month to reduce to twice daily .which we was promptly changed as per advice. Duloxetine, Pregabalin; Amitriptyline and Olanzapine were started due to her chronic facial Promethazine was started by Raid on the 11th September 2017. She had a follow up appointment with mental health that she not attend. As Miss Shaw' $ engagement with the community mental health team was compromised this may have had an effect on continuing the Promethazine. However; I do agree this should have been picked up during medication reviews and encouragement given to attend her appointments with the community mental health team. Perhaps a reducing regime agreed with the patient would have been another suggestion. Miss Shaw' $ medication was listed in the letter from MSK clinic. However [ note that Methadone was omitted from the list. am not sure whether Miss Shaw disclosed her Methadone intake and perhaps some of the chronic pain medication such as Amitriptyline, Duloxetine, Pregabalin and Promazine could have been avoided if the clinic were aware ofher methadone or Butane use. Inote a mental state exam was done at this clinic and there was no evidence of depressive cognition: Inote that there were several opportunities where she could have had some ofher chronic pain medication reduced. However these were missed. Again this will be avoided in future when a clinical pharmacist is employed by the practice and can go through complicated medication reviews The GPs in the practice are aware of this as a significant event and will be mindful of patients on sedatives, chronic medication with methadone and substance abuse. Records This is related to the commissioned provider and [ that can resolve this issue with the transfer of full records with a new provider. We, at Hopwood House Medical Practice are deeply saddened that Miss Shaw' $ death could have been as a result of poor communication and that steps could have been taken early to prevent this death. Unfortunately we have had to learn humbly from this and will in the future be much more vigilant with communication and correspondence, and also medication reviews. Changes have already been made; to prevent any further similar deaths and will be ongoing in the future. forward [ that communications with our and alcohol, and other services improve to ensure that we are made aware of the dangers of Butane. I have also suggested to Tier pain they Smg Smg pain did pain pain pain hope they Going hope drug

the practice that we add Methadone to the patients medication list in all cases to highlight to clinicians that are receiving this from the and alcohol team_ The practice would also, if supported through Oldham CCG have a meeting with Turning Point separately as a learning event to see what further changes we can both make to make sure miscommunications are avoided in the future Please express our deep condolences to the family_