Dear Ma'am Re: The late Ms Ivanika Olivari am writing in response to the Prevention of Future Deaths report that you issued jointly to St. George's University Hospitals NHS Foundation Trust; the General Medical Council and the Secretary of State for Health and Social Care following the inquest touching the death of Ms. Ivanika Olivari which took place on 19 October 2017 and 21 February 2018. note that the matters of relevance to St George's are set out at paragraphs 1 5 under "Coroner's Concerns" For ease of reference, these concerns are: That doctors should leave messages on answerphones for patients to make contact with them in urgent and emergency situations That doctors should attempt to contact patients via all contact phone numbers that have access to for patients in urgent and emergency situations That in urgent and emergency situations risk to life should be considered the priority That SGH hospital guidelines in relation to such matters should be updated and amended to reiiect the above where needed: That SGH should ensure that all relevant staff have their training updated in a prompt and auditable fashion to reflect the concerns raised above: The relevant Trust document that covers communications with patients is the Trust's Confidentiality Code of Conduct which falls within the remit of the Information Governance office, with the Executive sponsor being by Dr Mark Hamilton in his role as Excellence in specialist and community healthcare they policy

Associate Medical Director and Caldicott Guardian. The policy applies to all staff and the current version of this document was issued in March 2017 with a review date set for March 2019. The relevant section of the policy which makes specific reference to contacting patients by telephone is within Appendix 1 of the document The guidance given to staff in the scenario where a phone call is not answered or where an answerphone kicks in is to ring back There is specific instruction to staff not to leave a message on an answerphone: The reason for this instruction was to ensure that messages to call back a clinic or a clinician does not inadvertently compromise the privacy of a patient should the message be picked up by an unintended recipient. However; in light of the concerns you raised in the PFD report, we have made immediate changes to the guidance in Appendix relating to leaving telephone messages, as follows: Contacting patients by phone Where the patient does not answer the telephone and there is no answerphone facility, you should make attempts to ring back Such attempts should be noted in the patient's notes or logged elsewhere, with dates and times, wherever possible. Where the call triggers an answering message with a facility to leave messages; staff may leave a brief message requesting a call back; if the reason for ringing the patient is not urgent Messages must be suitably worded so as not to divulge any personal data as defined in section 3.1 of this policy. In an urgent or emergency situation, staff must leave a brief message requesting a call back; being careful not to divulge any personal data. In an urgent or emergency situation, staff should make further attempts to contact the patient via any other contact phone numbers that they have access to for these patients In an urgent or emergency situation; the risk to life should be prioritised and attempt made to leave an appropriately worded message for the patient to contact the team caring for the patient We hope you will agree that the above change in the guidance now given to staff has fully taken on board the concerns you raised in paragraphs 1 3 In respect of paragraph 4, as explained above, Appendix of the Confidentiality Code of Conduct policy has been amended to reflect the concerns you raised to enable staff to leave telephone messages for patients in urgent and emergency situations Having to review and amend Appendix 1 of the policy has presented an opportunity for the Information Governance office to forward the scheduled review date of the whole policy document to reflect the changes in new General Data Protection Regulations The updated policy will go through the relevant policy stages and will be published by autumn of this year: In the meantime; the updated Appendix 1, together with the learning from this case, has been disseminated throughout Cardiology services_ and is due to be reported to the next Patient Safety and Quality Committee meeting in May and communicated to the wider organisation via the communications department thereafter Excellence in specialist and community healthcare every bring the

The changes in the policy will also be highlighted at the Information Governance Committee meetings and in all Information Governance training sessions A link to the policy will be easily available to all staff through the Information Governance intranet pages. hope; with these measures, that you are reassured that the matters of concern that you raised subsequent to the inquest have been taken very seriously by the trust and that we have taken immediate action to ensure that the policy is updated to address your concerns and all staff are made aware of the change in guidance in relation to leaving telephone messages for patients in urgent and emergency situations_ Please do not hesitate to contact me if | can be of further assistance or if you have any residual concerns

Dear Dr Wilcox; We are very to hear about the death of Ms Ivanika Olivari and have taken time to consider the concerns and issues raised in the report: I will address each of the points for the General Medical Council (GMC) in turn. The GMC considers its guidance for doctors and amend where necessary to ensure that it is clear that messages may be left for patients in urgent and emergency situations: As you may know; one of the roles of the GMC is to describe what good medical practice looks like, and to set out the professional values, knowledge, skills and behaviours required of all doctors working in the UK We do this in a document called Good_medical_practice (2013) which is supported: by explanatory_guidance covering an extensive range of issues: The guidance is necessarily expressed as high level principles as it applies to all doctors, in all specialties, and across the four countries of the UK. It applies to all registered doctors, whether or not hold a licence to practise and regardless of their specialty; grade or area of work (for example, NHS or jndependent practice). In Good medicaL_practice we explain that doctors must take prompt action if think that a patient's safety, dignity or comfort may be seriously compromised; (paragraph 25). Working with doctors Working for patients The GMCis a charity registered in Erigland and Wales (1089278) and Scotland (5C037750) sorry they they

In Confidentiality:_Good_practice_in handling_patient information (201Z) we advise doctors on communicating with patients. In this guidance we advise doctors to communicate with patients in a format that suits both the patient and the situation as long as appropriate safeguards are put in place (paragraph 132) This can include voicemails: At paragraph 133 we expand on this to specifically address the issue of voicemail messages and confidentiality as follows; Most communication methods pose some risk of interception for example messages left on answering machines can be heard others and emails can be insecure: You should take reasonable steps to make sure the communication methods you use are secure: Given the nature and remit of our guidance, we do not give further procedural advice on what specific steps doctors should take when weighing up whether to leave a voicemail message, or what its contents should be: However the guidance is clear that while confidentiality is an important and legal duty it is not absolute and the safety of patients must be taken into account; In line with the general approach in the guidance; a decision not to leave a message would need to be balanced against the harm (or lack of benefit) to the patient in delaying communication and perhaps further treatment as a consequence Whilst our guidance provides doctors with a framework from which to work within, we do expect doctor's to exercise their own professional judgment to apply the principles to the situations they face in practice; and to be able to justify their decisions and actions. All our ethical guidance is available at WWWgmc-Ukorg: That the GMC and the Department of Health both take steps to ensure that the clarifications as outlined above are communicated to all doctors by the GMC and to all relevant staff employed by the NHS by the Department of Health: We have recently launched an updated interactive website (www_gmc-Ukorg) and are working on extra resources to expand our ethical guidance hub and learning materials for doctors We also have an extensive social media platform: We currently considering how best to use these communication channels to remind doctors of their duty to take prompt action if think that a patient's safety , dignity or comfort may be seriously compromised and the communication methods that may be available to do this: We will also alert the Information Governance Alliance (which is the authoritative source of advice and guidance about the rules on using and sharing information in health and care in England) to the absence of guidance for NHS staff on the use of voicemail: The GMCis charity registered in Working with doctors Working for patients Frigland and Wales (1089278) and Scotland (SC037750) by are they

Ido hope this:information is helpful to You; if you need any further information, please don't hesitate to get in touch with me; Yours fajthfully Head of Strategy and Planning Standards & Ethics Team General Medical Council Regent's Place, 350 Euston Road, London NW1 3JN Tel: 020 7189 5367 Email: fionnula flannery@gmc-ukorg Working with doctors Working for Patients Thz GMC is charity registered I} England and Wales (1089278) ard Scotland (SC037750)