PFD report

Suzanne Rose Eccles · Prevention of Future Deaths report

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Issued 19 Sep 2024•Manchester South

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

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Concerns
1

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
8

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised1

  1. Lack of a system enabling Emergency Department clinicians to easily access Virtual Ward records
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.7

  1. Action

    Operate an alert process on Lorenzo prompting Emergency Department staff to review virtual-ward patient status until GMCR access launches.

    Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 19 September 2024.
  2. Action

    Obtain Docobo contract approval and enact the change notice to enable the GMCR virtual-ward record for Emergency Department access.

    Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 19 September 2024.
  3. Action

    Complete clinical safety work enabling Emergency Department staff to view virtual-ward patient observations through the GMCR.

    Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 19 September 2024.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Lack of a system enabling Emergency Department clinicians to easily access Virtual Ward records

Wider context from the report

“Whilst the court heard evidence as to significant work which has been undertaken following the Trust’s detailed investigation into the circumstances leading to Mrs Eccles’s death, it is a matter of concern that no system currently operates whereby clinicians working in the Emergency Department can easily access records made by colleagues working on the Virtual Ward. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Operate an alert process on Lorenzo prompting Emergency Department staff to review virtual-ward patient status until GMCR access launches.

Verbatim wording from the response

“Once the GMCR record is operational, ED will have their own direct access to the GMCR through the icon. Until this is launched on 16th April 2025, there is an alert process on Lorenzo that will prompt staff to review the position on Virtual Ward which has been in place since the inquest in September 2024.”

Source location

Response from Tameside and Glossop Integrated Care NHS Foundation Trust
Page 3 · response
Published 19 September 2024

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Obtain Docobo contract approval and enact the change notice to enable the GMCR virtual-ward record for Emergency Department access.

Verbatim wording from the response

“The Trusts’ Neighbourhood Clinical Lead has engaged in multiple discussions with the GMCR Team and the Chief Digital Office for Greater Manchester Integrated Care Partnerships (GMICB) who have confirmed that the Trust can have access to the system. The Change Control Notice (CCN) was sent to be switched on circa 16th October 2024 and we were informed it would take 3-4 weeks but this was subject to delay from the provider. It was hoped that this would have been completed sooner but was subsequently delayed due to a financial barrier. This has now been resolved.”

Source location

Response from Tameside and Glossop Integrated Care NHS Foundation Trust
Page 2 · response
Published 19 September 2024

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Complete clinical safety work enabling Emergency Department staff to view virtual-ward patient observations through the GMCR.

Verbatim wording from the response

“Subject to the above all being signed off, the Docobo icon on the GMCR is intended to go live on 16th April 2025. Clinical safety has been carried out by the Trusts’ Chief Clinical Information Officer so that all ED staff can see the virtual ward patient observation, then the Trust will commence the training of all ED and Digital Health staff on the GMCR which we anticipate will take 3-6 weeks to implement, from 16th April 2025.”

Source location

Response from Tameside and Glossop Integrated Care NHS Foundation Trust
Page 2 · response
Published 19 September 2024

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Change the EMIS alert process to prompt clinicians to review GMCR records and care plans once the GMCR is operational.

Verbatim wording from the response

“Until the GMCR goes live, all patients admitted to the virtual ward have an alert added to community EMIS informing that the patient is on the virtual ward. EMIS is a clinical software system used in primary care, acute care and community pharmacy. Following the period of care, this alert is removed. Once the GMCR is operational, the alert process will remain on EMIS but will be changed to prompt clinicians to review the GMCR record/care plans. This will be led by Digital Health.”

Source location

Response from Tameside and Glossop Integrated Care NHS Foundation Trust
Page 2 · response
Published 19 September 2024

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Maintain the electronic Virtual Ward Patient Management Board with live patient updates accessible across the acute organisation.

Verbatim wording from the response

“In addition to the above, an electronic Virtual Ward Patient Management Board has been created and is available across the acute organisation, with live and current patient updates across all departments. Bed managers are able to see and access this Ward Board. It is just out of development and is being moved to the Emergency Departments Clinical Portal System, so that it will make it easier to see the list of patients currently under the care of the Virtual Ward. The board provides information about the level of risk that a patient is at whilst on Virtual Ward and the number of contacts that they have had each day and what condition they are being monitored/supported at home for. This board enables ED Teams to have full access to patients twenty-four hours each day, seven days a week.”

Source location

Response from Tameside and Glossop Integrated Care NHS Foundation Trust
Page 2 · response
Published 19 September 2024

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Train all Emergency Department and Digital Health staff to use the GMCR.

Verbatim wording from the response

“Subject to the above all being signed off, the Docobo icon on the GMCR is intended to go live on 16th April 2025. Clinical safety has been carried out by the Trusts’ Chief Clinical Information Officer so that all ED staff can see the virtual ward patient observation, then the Trust will commence the training of all ED and Digital Health staff on the GMCR which we anticipate will take 3-6 weeks to implement, from 16th April 2025.”

Source location

Response from Tameside and Glossop Integrated Care NHS Foundation Trust
Page 2 · response
Published 19 September 2024

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Move the Virtual Ward Patient Management Board to the Emergency Departments Clinical Portal System.

Verbatim wording from the response

“In addition to the above, an electronic Virtual Ward Patient Management Board has been created and is available across the acute organisation, with live and current patient updates across all departments. Bed managers are able to see and access this Ward Board. It is just out of development and is being moved to the Emergency Departments Clinical Portal System, so that it will make it easier to see the list of patients currently under the care of the Virtual Ward. The board provides information about the level of risk that a patient is at whilst on Virtual Ward and the number of contacts that they have had each day and what condition they are being monitored/supported at home for. This board enables ED Teams to have full access to patients twenty-four hours each day, seven days a week.”

Source location

Response from Tameside and Glossop Integrated Care NHS Foundation Trust
Page 2 · response
Published 19 September 2024

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.1

  1. 1

    Print virtual-ward patient information daily and provide copies to the Emergency Department reception team for out-of-hours awareness.

    Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 19 September 2024.

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Print virtual-ward patient information daily and provide copies to the Emergency Department reception team for out-of-hours awareness.

Verbatim wording from the response

“A hard copy of the virtual ward is being printed off daily by Digital Health and a copy is provided to the reception team in the Emergency Department (ED), so that out of hours and ED are aware of who is being monitored.”

Source location

Response from Tameside and Glossop Integrated Care NHS Foundation Trust
Page 2 · response
Published 19 September 2024

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026