Dear Sir Inquest touching the death of John Mellor write in relation to the above inquest which was held before you on 13 February 2019. Following the inquest you issued a Regulation 28 report. Box of this report addresses it to Sir David Dalton, Chief Executive of the Northern Care Alliance Group ("NCA") (amongst others) Firstly, thank you for bringing the concerns raised in the Regulation 28 report to our attention: would like to take this opportunity to provide assurance to both you and the family that Salford Royal Care Organisation ("SRFT") takes the concerns raised very seriously and action has been taken to address these as detailed below As you are aware, Pennine Acute Hospitals NHS Trust ("Pennine Acute" 'was considered an Interested Person and witnesses from Pennine Acute gave live evidence_ You also heard evidence from SRFT by way of a single statement read under Rule 23. SRFT were not given Interested Person status at the inquest and therefore did not attend: SRFT would have welcomed the opportunity to give evidence to your inquest to explain the steps that had already been taken to address the concerns that you have raised. SRFT first became aware of the Coroner's concern following receipt of the Regulation 28 report: would like to take this opportunity to apologise to Mr Mellor's family that the inquest process has been extended through the Regulation 28 process Discussions have taken place with representatives from Oldham Care Commissioning Group ("CCG"), St Chad's Medical Practice and Pennine Care Foundation Trust: Cross- organisation learning has been shared and we are assured that' there is now robust 2nd

Saving lives, NHS Improving lives Northern Care Alliance NHS Group Salford | Oldham | Bury Rochdale North Manchester tracking system within SRFT for patients requiring Erythropoietin Stimulating Agents ("ESA") treatment and monitoring their bloods Erythropoietin ("EPO") is a specific hormone that falls into the ESA drug group. Regulation 28 concerns and response: Systematic failure to ensure that blood tests are conducted,, where required, for individuals under specialist, secondary care for renal failure_ Failure to establish a shared care arrangements, or at least ensure that an organisation was identified in order to undertake blood sampling for drug monitoring is insecure and unsafe_ Following discussions with the CCG, it is recognised that this is a Greater Manchester issue_ SRFT has looked at both immediate actions and long-term solutions to address the concerns raised and the lessons that have been learned will be shared with the Renal Patient Safety Committee which is a joint venture with the British Renal Society: The Renal Patient Safety Committee works closely with the Medicines and Healthcare products Regulatory Agency (MHRA) and NHS Improvement and aims to minimise avoidable harm to patients with kidney disease_ Immediate actions to assure patient safety The wording of letters to patients has been modified to ensure the options available to them for arranging blood tests is very clear and of contact at SRFT is provided if the patient is having any difficulty. Patients may attend the renal clinics at Salford, Wigan, Bolton and Oldham for pre-arranged blood tests_ Prior to commencement of treatment, a letter is now Sent to the patient's GP when the Renal Consultant is considering ESA treatment to make the GP aware of this and to ask if they are able to monitor the patient's bloods. A returns slip is included so that this can be completed and administrated efficiently: When SRFT are aware of the GP's position in respect of the patient's bloods, an appropriate blood monitoring plan is agreed with the patient at the time of the prescription of ESA This method enhances the informed consent process for ESA treatment as the patients will have an understanding of the full implications of the monitoring required. SRFT's Electronic Patient Record System ("EPR") has been updated with a section confirming when GP has responded in respect of monitoring: If no response is obtained from primary care, this is followed up by the renal clerical team: point

Saving lives, NHS Improving lives Northern Care Alliance NHS Group Salford | Oldham | Bury Rochdale North Manchester Until SRFT receives response from the GP , we assume responsibility for taking bloods to ensure that patients start ESA treatment when clinically necessary: A Standard Operating Policy has been developed which describes the above process and the steps taken when negative response is received, or when a response is outstanding: A copy of the Standard Operating Policy is attached. In order to track all patients receiving ESAs, SRFT's EPR system has been updated to show when patients' blood results are due, and those that are missing and require follow up_ Prescribers have allocated time,in their job plans for ESA monitoring and prescribing: The new EPR system always shows the most recent haemoglobin results for the patient: These improvements will provide assurance not only in respect of new patients who start ESA treatment, but also current patients. All patients currently receiving ESA treatment will be written to by the renal admin team by the end of May 2019 to establish whether experienced any difficulties in accessing appropriate monitoring: Patients experiencing difficulties will be managed in accordance with the agreed SOP . Long-term plan Patients under the care of SRFT renal services often do not live locally to the renal unit so if monitoring is required to be undertaken at SRFT, this is often not the best or most appropriate solution. Previously, there was no agreement or shared care protocol in place between SRFT and its CCG catchment primary care providers for the monitoring of bloods. As above, following discussions with the CCG, it is recognised that this is Greater Manchester issue_ We are exploring via CCGs and the Greater Manchester Medicines Management Group the possibility of Greater Manchester commissioned shared care protocol for monitoring of ESAs. Responses or updates to referrals; as well as requests for tests in the community have not been communicated to primary care directly: Rapid Review has been completed to ensure all lessons to be learned this incident have been identified and to ensure the learning can be embedded. The Rapid Review included a thorough review of the timeline of correspondence sent to Mr Mellor's GP. apologise unreservedly on behalf of SRFT for any perceived shortfalls in respect of SRFT's communication to Mr Mellor's GP. they have from

Saving lives, [HS} Improving lives Northern Care Alliance NHS Group Salford Oldham Bury Rochdale North Manchester Going forward, GPs will be copied in to all correspondence to the patient, including correspondence advising the patient that - are due to have their bloods tested. Next steps trust that this response provides assurance that lessons have been learned from this case and demonstrates the improvements that have been made to systems at SRFT. would Iike to conclude by once again apologising to Mr Mellor's family for the issues in his care that have been identified above and that the Inquest process has been extended through the Regulation : 28 process; We would have- much preferred to have had the opportunity to explain this in person at the Inquest_ would wish to offer my deepest condolences to Mr Mellor's family on their loss_ Please do not hesitate to contact me if you require any further information. Yours sincerely Chief Officer Salford Royal NHS Foundation Trust Northern Care Alliance NHS Group Comprising Salford, and Rochdale, Oldham and North Manchester Care Organisations they Bury

NHS Oldham Clinical Commissioning Group If calling please ask for: John Patterson Ellen House Direct line: Waddington Street Email: Oldham OL9 6EE ( 0161 622 6400 wwwoldhamccg nhsuk 11 April 2019 Nicholas Flanagan Assistant Coroner Manchester Area Office of HM Coroner The Phoenix Centre LICpl Stephen Shaw MC (formerly Church Street) Heywood OL10 1LR Dear Mr Flanagan Re: John Mellor DOD October 2018 Further to your Regulation 28 report of 14"h February 2019 following the inquest into the death of Mr Mellor on 12/h October 2018, confirm that a full investigation into the matters you raised has been completed by the care organisations responsible for the care of Mr Mellor. am noW in a position to respond to the concerns raised into the circumstances surrounding the death of Mr Mellor. The matters of concern raised and the actions we will take to address these concerns are as follows: That there appears to have been systematic failure to ensure that blood tests are concluded, where required, for individuals under specialist secondary care for renal failure: Individual patients; who may not be local to the specialist centre; will inevitably fail to have the appropriate assessments, care and treatment in the absence of a clear line of responsibility: 2 The failure to establish a shared care arrangement; or at least that an organisation was identified in order to undertake blood sampling for drug monitoring; is insecure and unsafe_ It is also concerning that responses or updates to referrals, as well as requests for tests in the community have not been communicated to primary care directly, with the sole reliance on patient to pass vital documentation on to his primary healthcare provider. The investigation has highlighted a number of contributing factors within the care system which prevented Mr Mellor accessing the necessary service which is extremely regrettable. There was Best Care Best Health Best Value Way 3ra

lack of systems and processes in place throughout the organisations to ensure follow UP, escalation and effective communication between all agencies involved in Mr Mellor's care. The absence of a clear line of responsibility within the system was evident within the investigation and demonstrates the need for a clear shared care pathway with accountability for action to ensure that the patient receives the appropriate level of care. In discussion with colleagues across the system it is apparent that there was no one individual taking responsibility for this gentleman's care, resulting in a level of assumption and an unnecessary and inappropriate level of responsibility placed on him and his family to be requesting blood tests In both the case of the referral to the District Nursing Single Point of Access and the Primary Care team; it is clear that escalation of the issues to a more senior clinician may have altered the course of these events and allowed more timely action to be taken This is something that has been identified by both the GP Practice and the District Nursing Team and forms part of the learning to prevent such occurrences in the future. From system perspective , there was missed opportunity for Mr Mellor to have his bloods taken at the blood lounge at Royal Oldham Hospital whilst he was on the Oldham site for the clinic appointment: This generates learning about satellite clinics and the awareness of the team as to what services may be available locally that the clinic can tap into. The review of the timeline of events with the GP Practice has demonstrated where gaps in communication have had significant impact: The failure to copy the GP in to the communication out to Mr Mellor meant that whilst he was struggling to access service to take his bloods, the GP was unaware that this was the case. When this was brought to light, there was an escalation within the surgery, however this was impacted by existing skills and capability along with annual leave arrangements_ Unfortunately this was not communicated back to the GP themselves and the investigation clearly recognised this as a missed opportunity The CCG instigated a system call to agree actions going forward as a collective, some of which will be described in greater detail within individual organisational responses The actions being led by the Renal Team at Salford Royal Foundation Trust have been to in place a standard operating procedure to communicate directly with CP's and ensure a response to any request for blood monitoring or any other service carried out locally; This will require a response from the local GP or provider before the treatment plan is confirmed: The Trust have confirmed that all correspondence with the patient will be copied to the GP_ On a longer term implementation is the development of a shared care model this has been described in business case to Greater Manchester Medicines Management Group which will then go out to local commissioners The Pennine Care Foundation Trust District Nursing single point of access service have implemented a follow up system to make sure that there is a response from the GP practice following referral. As a backup measure, where patients have been referred to another part of the system they are told that should encounter any problems they are to come back to the District Nursing who can then intervene on their behalf All staff within the GP practice are currently undergoing significant training in escalation and administrative processes. Common practice is for GPs to provide a phlebotomy service so that the patients care is close to home_ Additional support has been offered by the CCG to ensure that all relevant staff are trained, up to date and competent to ensure that they can deliver this service. Learning will be shared across the Northern Care Alliance (NCA) and communicated to Central Manchester Foundation Trust to ensure that shared care protocols are reviewed and that others can learn from the communication errors that occurred for Mr Mellor_ Oldham CCG have been working Best Care Best Health Best Value put being they Team

with the medicines optimisation team to identify all individuals who may be on (or fit the profile of) a shared care pathway_ There have been 43 individuals identified that are currently receiving Epoetin or Darbepoetin: We have written to each GP practice to share the learning from this investigation and to ensure have reviewed any patient that fits these criteria and that there is robust monitoring process in place NCA have also been asked to identify patients and escalate to CCG if they have any concerns 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 us should you wish to discuss any further concern: Yours sincerely RU tu MA MRCP MRCGP Claire Smith Chief Clinical Officer & Deputy Accountable Officer Executive Nurse NHS Oldham CCG NHS Oldham CCG Best Care Best Health Best Value they.

NHS Pennine Care NHS Foundation Trust gth April 2019 ServicelDepartment Name Trust Headquarters 225 Old Street Ashton-under-Lyne Lancashire OL6 7SR Strictly Private and Confidential Nicholas Flanagan Telephone: 0161 716 3000 HM Assistant Coroner HM Coroner's Office The Phoenix Centre L Cpl Stephen Shaw MC Heywood OL10 1LR Dear Mr Flanagan Re: John Mellor - DOD 3rd October 2018 write following the Inquest of John Mellor. concerns after hearing all the evidence have been brought to my attention and have subsequently reviewed the Regulation 28 letter issued to Pennine Care_ am writing to respond to the concerns raised into the circumstances surrounding the tragic death of Mr Mellor. The matters of concern raised and the actions we will take to address these concerns are as follows: That there appears to have been a systematic failure to ensure that blood tests are concluded; where required, for individuals under specialist secondary care for renal failure. Individual patients, who may not be local to the specialist centre, will inevitably fail to have the appropriate assessments, care and treatment in the absence of a clear line of responsibility: The failure to establish shared care arrangement; or at least that an organisation was identified in order to undertake blood sampling for drug monitoring; is insecure and unsafe. It is also concerning that responses or updates to referrals; as well as requests for tests in the community have not been communicated to primary care directly, with the sole reliance on patient to pass vital documentation on to his primary healthcare provider. I can confirm that a referral was received on 28/8/18 into the Oldham Single Point of Access (SPoA) for Adult Community Nursing from the Department of Renal Medicine at Salford Royal NHS Foundation Trust: The SPoA is a central point of access via telephone or email which provides a gateway to a range of health services including Adult Community Nursing for patients, carers and 4 Visit us at www penninecare nhsuk 8 Way Your About 1 O1SABLC9

professionals_ The service is delivered by nurses who triage and manage the referral process with the support of administrators. The referral received did not arrive in the usual format as a recognised referral form and was more letter. The letter did not contain all the relevant information required to triage effectively, for example it was not dated and did not detail if the patient was housebound which would assist in determining which team the referral would be allocated to. Additionally, the telephone number that was recorded on our Paris recording system for Mr Mellor was not in use and there was no patient telephone number documented on the referral therefore the SPoA requested an up to date contact number from the renal unit for the patient in order to arrange an appointment: The Oldham Adult Community Nursing service provides care for patients who are housebound, either permanently or temporarily, requiring treatment in their own home. There is also a Treatment Room service based in clinics across the borough for those patients' not housebound but requiring District Nursing interventions. The service is commissioned to deliver a phlebotomy service to housebound patients only. It was determined from the response received on 29th August 2018 from the Renal Unit at Salford Royal, confirming Mr Mellor's contact details that he (Mr Mellor) was not housebound. It was also identified through the Paris recording system that Mr Mellor was attending podiatry clinics most weeks therefore the referral was forwarded to the GP practice for blood pressure monitoring and phlebotomy (full blood count), via email, as is the correct process for the service. Had Mr Mellor been unable to self-administer his injection he would have been offered an appointment in Treatment Room clinics for his injection, blood pressure monitoring and full blood count as is the correct process. Our records confirm, that the practice manager from Mr Mellor's GP practice contacted the West Cluster Integrated Community team (who are aligned to the practice) to ascertain if the recommendations from SPoA were correct; the duty nurse confirmed this to be the case and this decision was not questioned or contested_ No further contacts after 31st August 2018 were made to the Adult Community Nursing service in relation to this referral. When Mr Mellor was contacted by SPoA on 31st August 2018, previous attempts to contact him on 29th and 30th August were unsuccessful, he was advised he was referred back to his GP practice to undertake the blood pressure monitoring and phlebotomy full blood count: An apology was given to Mr Mellor for the misunderstanding: The nurse contacted the surgery to advise of this conversation with Mr Mellor and confirm to the practice that the referral was forwarded to them by email on 29th August 2018 when it was identified the patient was not housebound_ Following the receipt of the Regulation 28 notice meeting was arranged by the GP practice. The Cluster Lead and Senior Practitioner from the West Cluster Integrated Community team attended the meeting that took place on 25th February 2019. GP's, Practice Nurse, Practice Manager and an administrator represented the GP practice. 2 Visit us at wwwpenninecare nhsuk O1saBL+9 being Abour 0 0

Both parties reviewed the information and timelines of events in regard to this referral to determine what collectively we would do differently if similar circumstances arose It was determined that based on the information available the SPoA and District Nurses followed due process and acted accordingly: It was acknowledged at that time the practice did not have capacity to facilitate the full blood count although were able to perform the blood pressure monitoring: It was acknowledged that there was a lack of understanding from the practice administrator in relation to the differences between the SPoA and the cluster team; this was addressed in the meeting: Had the practice staff and cluster team discussed the case a resolution could have been identified. This could have included Mr Mellor attending Treatment Room for supervision of this injection alongside blood pressure monitoring and full blood count: Alternatively, it may have been possible to arrange for Mr Mellor to have his blood taken whilst he was attending his Podiatry appointments. It is evident that Mr Mellor's ability to self-manage part of the treatment plan, (his injection) resulted in him not receiving the appropriate support to manage his condition safely and appropriately. Following this incident and to ensure the learning is communicated, the Cluster Lead is meeting with SPoA staff to ensure that when referrals are forwarded to another provider that patient is informed of reason for this. Patients will also be advised to contact SPoA should any issues arise and SPoA staff will then escalate to cluster teams to resolve_ A 'lessons learned' poster is developed to share across community services in support of this. Oldham is entering phase 2 of integration having successfully co-located health and social care community teams around GP clusters to provide a whole system approach to delivering high quality care in a more joined up way and it is these closer working relationship and links between providers that will improve communication between members of the MDT hope that the information provided offers assurances in relation to your concerns. Please do not hesitate to contact me should you require any further information. Yours sincerely UAZMW Clare Parker Executive Director of Nursing; Healthcare Professionals & Quality Governance 3 8 Visit Us at www penninecare nhs uk they the the being About 0 0 015A8Lt9

Oldham Chads OL8 3HH Tel: 0161 620 1611 stchads medicelpractice@nhs net Medical Practice Mr Nicholas Flanagan Asslstant Coroner (Manchester North) APR Dear Mr Flanagan, Re: Inquest concernlng Mr John Mellor (deceased) Thank for your letter of 14 February 2019 encloslng the Reglatlon 28 Report for te Pravention 0cFuOue Deters On light ofyour Investigation into the death Ol Mr Mellor:' Noetrepore was also sent tc lat Oidham Care Commisslonlng Group lat North Care at Pennlne Care Foundatlon Trust In addltion to St Chads Alllance NHS Group Medlcal Practlce: Background St Chads Medical Practlce ("the Practice") contracts wlth the Oldham Care Commlssionlng Groue ("the CCG" ) to provlde primary care servlces to around 3000 registered patlents wlthln the immedlate surrounding area: The Practlce also provldes some monltoring of medicatlons preserlbatd utfro econdaiecare under a Series ofshared care agreements whlch are negotlated by the CCG wlth Secondary Care; Prlor to early 2018, the majorlty of the secondary care servlces provlded to patlents reglstered at Fhe Frecttce would be through the Pennine Acute Trust; Wlth some speclallst care provlded through Salford Royal NHS Foundation Trust Renal Servces were provlded through Salford Royal NHS Foundation Trust; whlch had a satelllte cllnlc at the Royal Oldham Hospltal: At the beglnnlng of 2018 the PennIne Acute Trust and Salford Royal NHS Foundatlon Trust merged Into the Northern Care Alllance ("the Trust ) Separate to thls the Pennlne Care Foundation Trust provldes addltlonal prlmary care support In the community, for Instance the use of Dlstrlct Nurslng In order to complle thls response; we have discussed your report the Issues that arose at the Inquest not only wlthin the Practice but also wlth the Dlstrlct Nurslng Team at the CCG. As & result of those discusslons varlous actlvltles have been arranged by dlfferent bodtes and thls report seeks to Identlfy those that are relevant to the Practlce, rather than those matters that are concerns for the CCG and the Trust: The Practlce dlvlded the concerns Into three areas of urgency; Red; Ensuring that there was no Immedlate risk to patlents wlthln the Practlce and alerting the CCG 2014 and and and

LulICIWiSL Oldham Chads OL8 3HH Tel: 016 1 620 4611 Medical Practice stchads medicalpraclice@nhs net Amber; Identlfylng where actlon should have been taken at the tlme Green: Putting In place measures to prevent reoccurrence In the future We have set out the steps taken by us In this regard below and enclosed a table which sets this out in more detall: Ensurlng that there was no lmmedlate risk topatients Ordinarily where Prlmary Care Servlces (GP Practlces and Dlstrlct Nurslng) are asked to arrange for ongolng monitoring for medlcatlon prescribed by secondary care; those medications are amber %r green status drugs under the Greater Manchester Cllnlcal Standards Board for MedIclnes ("GMMMG ) Jolnt Formulary: EPO (Erythropolesls stdmulatlng medlcatlon) red status medicatlon under the Greater Manchester Jolnt Formulary (GMMMG}: Red status medlcations according to GMMMG are "for secondary or tertlary care Initlatlon and iong-term malntenance of prescrlbing: Amber status medlcatlons are described as "drugs whlch are approprlate to be Inltlated and stabllised by a speclallst In secondary or tertlary care once stabillsed the drug moy be approprlate for responslbility to be transferred from secondary to prlmary care wlth the agreement 0 a GP and a formal 'shared care' agreement The GMMMG publish the approved shared protocols for those 'drugs on thelr website whlch Include detalls such as dosage, baseline Investlgatlons, ongolng monltorlng who Is responslble for the dose adjustments, drugs whlch must not be prescrlbed wlth the medicatlon, criterla for shared care and the express responslbllitles of the Initlatlng cllnlclan and prlmary care, amongst other crlterla In addltlon there are three levels of green status medications whlch can be prescrlbed by prlmary care wlthout a shared care agreement they are those that have to be Inltlated In secondary care but requlre Ilttle monitoring those that are prescrlbed following speclallst medication requiring Ilttle monltorlng and then whlch can be instlgated, monltored and revlewed wlthln prlmary care: Shared care agreements are negotlated between secondary care and the CCG They are not matters that are usually negotiated between secondary care and an Indlvldual General Practlce surgery; Where the Practlce Is Indlvldually contacted the approprlate guidance Is "The Interface between prlmary and secondary care messages for NHS Clinlclans and Managers" (July 2017) The Practlce should have alerted the CCG to the fact that they were belng asked to arrange monltorlng of & red status medlcation so that the CCG could Ilalse wlth secondary care and Medlcatlon Management We wrote to the CCG on 11 February 2019 to notlfy them of thls slgnlficant event and the upcoming Coroner s Inquest; Please find a copy of that letter enclosed wlth thls response: Followlng the Inquest a Practlce audlt was undertaken on 15 February 2019,whlch conflrmed that there are no other patlents at the Practlce under the care of the Renal Team who are currently prescrlbed EPO or recelving monltoring: Please fnd copy of that Audlt enclosed wlth thls response: drugs - Key

Diliuiot Oldham Chads OL8 3HH Tel: 0161 620 1611 Medical Practice gtchadsmedicalpractice@nhsnet Durlng telephone call wlth at the CCG on 29 March 2019,the Practice was Informed that 'ashoepaooe agree to the monltoring of red category medlcatlons and should notlfvrthe CCG neyshoaskeaoto doeeo Thee CCG are Ilalsing dlrectly with the Trust and also wlth Medicatlons urgently regardlng thls Issue At the request of we have wrltten to the Trust Management with them directly in relation to the isues Identlfled by the Practlce and by and the CCG are Ilalsing the CCG_ Ldentlfvlng where Improvements were required The Practlce undertook two separate Investlgations arlslng from JM's case; An {investlgation Into what had happened t9 the letter from the Renal Adnolstratlve Team atthe Royal Salford Hospltal to IM,when the Next of kln brought It to receptlon: Significant Event Analysls, which took place with Input from the Dlstrlct Nurslng Team on 25 February 2019. One of the concerns ralsed by yourself was the potential for vulnerable patlents to fall through the "of cere between providers The Practice has recently been Inspected by the CQC (report not Yeps %allable) as part of that process the Practlce has recently reviewed staff tralnlng In and the Practice"s Safeguardlng procedures and all stalf members are up to date We Gnecefordlngaanothendertike 0 further Investigatlon' Into staff tralnlng In safeguarding_but coersederetion of patient vulnerabllity was dealt with In the SEA and followed up durlng the clinical meetlng on 18 March 2019 of the SEA Is enclosed wlth thls letter and the table sets out the fIndings and actions copy undertaken aS a result of these (nvestlgatlons Steps taken bythe Practice The CCG have advlsed the Practice that Ifwe are asked to accept responslbillty for the monltorIngof PhGErG prescrdedegPoeby secondary care again we_should not accept Ghar responsohitorlmthat fhls aetnforesg thet It was the right decision not to agree to undertake the ongolng monitorlng that thes Reenad Teamahad Wsked JM to arrange; the Practice were concerned that our Sstems fr the concern withln and outside the Practice were not as robust as they should have been: escalating The Practlce has Identifled areas where staff requlred tralnlng staff needed to be remlnded of Procedures Procedure needed to be In place. Thls tralning and need Is set out In Practlce Or a the table enclosed wlth thls letter; In the green sectlon: Tralnlng has been dellvered through Practice meetings: The Practice holds weekdy non-cloecaf meetings and fortnighdly clinical meetings In addition to monthly Practice meetlngs focthce hboleis Tear aThisotralning has been relnforced with follow up emalls to all staftf The Practlce has also the audits to ensure that the changes have been effectlve and to Identlfy any scheduled revlews ongolng patterns of concern Please see the enclosed table The Practlce has updated the CCG with the (ndings from these Investigatlons and the Ind gcchcve been fed back to staff at the Practice As mentioned above the CCG have requested that the Practice not - yet put and

Oldham Chads OL8 3HH Tel: 0161 620 461 stchads medicalpractice@nhs net Medical Practice does not wrlte to the Renal Team as they are golng to correspond dlrectlv wltbice @ndsteviewdug ratsed Inethle aase We will continue to keep thls matter under revlew and review our the Issues recelve further feedback from the CCG processes agaln once we find the Informatlon set out In the table attached useful and we would be happy We hope that detall: Your office Is welcome to contact Dr GIII on to dlscuss these Issues In more further: toarrange a convenlent tlme to discuss thls matter