Rt Hon Alistair Burt MP Minister of State for Community and Social Care Department of Health Richmond House 79 Whitehall London SWIA 2NS POC3000915979 Tel:] Ms J, Leeming Senior Coroner Coroner's Officer HM Coroner's Court Paderborn House, Howell Croft North 2 3 JUL 2015 Bolton, BLI IQY Iev M, Thank you for your letter of 11 2015 following the inquest into the death of Margaret Wright; I was very sorry to hear of Mrs Wright's death and wish to extend my sincere condolences to her family: There are two areas of concer that you raise for our attention as a result of the inquest: The first relates to the system of GP patient home visits: At the time, the doctors at Mrs Wright 's local GP practice did not routinely phone the patient or family members to obtain further information about the patient'$ situation following request for a home visit, Had this happened at the time, then Mrs Wright would have received a priority visit (although you out that this may not have altered the outcome): Since Mrs Wright's death a system of phoning the patient/family to a home visit has been introduced by the GP practice concerned and in the local area. The second, and most concerning, highlights the fact that the GP practice did not receive a patient discharge summary for Mrs Wright; from Manchester Royal Infirmary, leaving the home visits doctor unaware of her recent surgery: The responsibility for sending a discharge summary rests firmly with the discharging Trust: The Trust has confirmed that, on discharge; & patient'$ discharge notification should be posted to their GP and a copy filed within the hospital '$ patient records Gx~ May point prior

Staff at the Trust have reviewed Mrs Wright'$ notes and have found that a copy of the discharge notification to her GP was electronically signed by the hospital doctor on & December 2014 and filed in her medical records. The notification contains details of diagnosis, treatment, discharge medication, out-patient follow up plans and other relevant information. Mrs Wright was discharged from hospital on 1 1 December 2014. Her GP should have received the discharge information by the time of her request for a GP home visit: The Trust cannot confirm that the letter was actually posted, or subsequently received; by the GP practice. This part of the process is not currently tracked or logged. However; the Trust is planning to utilise email and electronic links to enable tracking of whether discharge information has been sent and received. On home visiting itself; GP practices, under contracts with NHS England; are required to provide services to their patients that include a home visit in cases where there is a clinical need. However; the clinical care of the patient in a home setting is one which needs careful consideration by the GP. The Royal College of General Practitioners (RCGP) is aware of the importance of this and its training curriculum includes advice on, and prompts GPs to consider; the risks of seeing patients in different contexts, including the home: The chapter of the Curriculum dealing with patient safety and quality of care contains a hypothetical illustration" setting out an account of the circumstances surrounding a patient'$ death, where home visiting had been a factor; and the challenges that the case presented to the practice. Doctors in training using this resource are prompted to consider how seeing patients in a different setting such as the home, on day, might impact upon clinical care http:/Iwww_rcgp org ukltraining-exams/gp-curriculum-overview/~Imedia/Files/GP- training-and-exams/Curriculum-2012/RCGP-Curriculum-2-02-Patient-Safety-and- Quality-Of-Care.ashx In addition, the importance of considering the contextual aspects of clinical care are emphasised in a further chapter of the GP Curriculum entitled "The GP in Wider Professional Environment"_ http ILwwwICgp Org ukltraining-exams/gp-curriculum-overviewl-Imedia/FilesGP training-and-exams/Curriculum-2012RRCGP-Curriculum-2-03-GP-In-Wider Professional-Environment ashx point "case key busy

Department of Health The introduction states: As a clinical and general practitioner at the frontline of health services, you will need to understand not only how to work within systems of healthcare but also how to work with those systems for the benefit of your patients This will require an understanding of the context; structures and processes in and by which care is delivered that goes beyond that of your specific clinical role" NHS England has advised that its Primary Care Patient Safety Expert ~ which focusses on primary care and general practice concerns, is currently considering home visits. At their next meeting; to be held within the next six weeks, the group will consider the best way to ensure home visits are appropriate to individual patient needs: I would be to update you with their findings in due course In addition; I understand the National Institute for Health and Care Excellence is currently drawing up guidance on "Home Care' with a planned publication date of September 2015. Furthermore, I can advise that NHS England is making efforts to improve the safety of patient discharge In August 2014,a Patient Safety Alert was issued which launched a national programme of work to support organisations in improving the communication and management of patient information at handover: One of the initial priorities is to share best practice to improve the quality and timeliness of communication. I hope that you find this reply helpful and I am grateful to You for bringing the circumstances of Mrs Wright's death to my attention: ~ow, Incx ALISTAIR BURT Oae O4F , rar 60s ~ K) 64 (L4 ~' € W wask &e L L" 6 J] cunifull Group; happy