Dear Mr Haigh Re: Audrey WAKEFIELD (deceased) Further to my letter dated 29 April 2014, am pleased to provide a response to your report under paragraph of Schedule 5 of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013, addressing your concerns surrounding the death of Mrs Wakefield. Background On 8 January 2013 Mrs Wakefield had a stroke and was admitted to the University Hospital of North Staffordshire NHS Trust (UHNS). She was discharged on 12 January 2013 and on 16 January 2013 moved to in a care home. On 21 February 2013 she fell at the home, attended Stafford Hospital and was discharged back to the care home: She was then admitted again to UHNS in poorly condition on 24 February 2013 but deteriorated despite treatment: She moved to the Douglas Macmillan Hospice on 10 April 2013 and died there the next day. Death resulted from the effects of the stroke and the fall on 21 February 2013. Concerns HM Coroner, Mr Andrew Haigh, raised concerns at the inquest regarding the standard of care afforded to Mrs Wakefield although he acknowledged that matters may well already be in hand. In particular; Mr Haigh commented that: At the inquest; was greatly assisted byl Consultant Stoke Physician at your hospital He indicated that when Mrs Wakefield was discharged from UHNS on 16 January 2013 the communication of relevant discharge information to Mrs Wakefield's GP was not good. The reason was that there is good communication system from the hospital and the GPs in the Stoke on Trent area but this did not apply to more distant practices (Mrs Wakefield's practice was in Stone) indicated that steps were taken to improve this. With Stafford Hospital moving to come under control of your Trust the situation could be quite serious as a number of GPs practices are likely to be involved. It may be that this is being addressed in any event but should be grateful it you could check that an effective system of discharge information will apply wherever a patient's GP practice may be situated: EolD Keele Ito siw Caring With Knowledge Cr (University Value Through Quality Wtute RerJctet 515a8L49 33 STAFES " SCUTC live being Mour

University Hospital of North Staffordshire [HS] NHS Trust Continued_ Under Paragraph 7 , Schedule 5 of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013, where the Coroner has concerns regarding the potential for future deaths, his function is to identify points of concern but not to prescribe solutions_ The UHNS was in the process of considering solutions for the matter identified by the Coroner and is able to provide an update on the current position. Action Taken The University Hospital of North Staffordshire NHS Trust has considered the Coroner's concerns and has outlined below the actions taken in conjunction with the wider Local Health Economy (LHE): UHNS does not have a unilateral obligation to resolve the issues and the Trust therefore continues to work in partnership with the LHE IM&T Group and the local Clinical Commissioning Groups_ At the time of the inquest UHNS had already implemented an electronic clinical correspondence solution across Stoke and North Staffordshire Clinical Commissioning Groups; this was implemented in 2011/12. This process facilitates the electronic delivery of discharge letters (including Maternity and ED letters) to all GP practices in Stoke on Trent and North Staffordshire. Currently, as was heard at the inquest; GP Practices outside of these areas receive a printed discharge letter: In order to facilitate the timely electronic distribution of discharge letters beyond Stoke on Trent and North Staffs Clinical Commissioning Groups, a solution has been developed with the system supplier to 'switch on' GP practices in South Staffordshire , Shropshire and Cheshire_ UHNS funded the one-off development of the solution with the supplier however there is requirement for each GP practice to pay an annual fee for the on-going delivery of electronic clinical correspondence. This is a matter requiring on-going negotiation although it is common practice nationally, for Clinical Commissioning Groups to fund this within their local area_ The GP practices in Stone were 'switched on' by 12 June 2014, including the GP practice which provided care to Mrs Wakefield. All of the remaining Stafford and Cannock GP practices (South Staffs) have committed to switched on by the end of July; this allows some time prior to UHNS and Mid Staffs Hospital acquisition which is due to occur on November 2014. A total solution for all areas is proposed to be delivered in three separate phases based on geographical area; South Staffordshire , Shropshire and Cheshire and wrote to them on 29 April 2014_ This include remote implementation and training where possible, and GP practices will also be supported by dedicated IT trainer, telephone support during implementation and Standard Operating Procedures. We are still awaiting confirmation from Western Cheshire, South East Staffs and Seisdon; Shropshire and Vale Royal and South Cheshire who have not yet confirmed that they will pay the annual practice charge: will write to them again to ask them to do this however it may be helpful for you to do the same given that the request came from you: sincerely hope that the information set out above provides H M Coroner; Mr Haigh, with assurance that the University Hospital of North Staffordshire NHS Trust has taken the matters arising from the inquest touching upon the death of Mrs Wakefield seriously. The Trust endeavours to learn from every opportunity where the standards of care expected by our patients have not been achieved and on this occasion, am pleased to see that the Trust was already in the throes of dealing with 40 BiolD Keele Caring With Knowledge @ito til JUniversity Value Through Quality Cat Mnjl iin o1sa8449 being will Jout Ltve

University Hospital of North Staffordshire NHS] NHS Trust Continued, 3 problems arising from the anticipated amalgamation of of Mid Staffordshire NHS Foundation Trust and UHNS_ Should you wish to discuss any aspect of this report further, please do not hesitate to contact me directly. Best wishes