Report evidence summary
× 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 Failure to recognise and flag the most appropriate antibiotic formulation for vulnerable patients
Wider context from the report “1. The inquest heard that Mr Shearer was frail and vulnerable with very poor swallow. When prescribing the clinicians did not recognise or have a system to flag up the need for liquid antibiotics rather than tablet antibiotics . This led to him not being able to commence antibiotics on the day he was identified as needing them . The inquest heard that it is important that in the community particularly for the vulnerable there is a system for recognising what form of antibiotics are most appropriate to prescribe for avoid delay .
” Is this part of a recurring concern? Yes — Unsafe medication prescribing .
Open source report × 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 Failure to provide face-to-face GP assessment when deterioration may be present
Wider context from the report “3. The inquest heard that he had not been seen face to face by a GP and that meant that the full extent of his deterioration was not recognised until he was seen by a paramedic from the practice who called an ambulance.
” Open source report × 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 ASK MY GP system making communication harder for vulnerable patients and their families
Wider context from the report “2. The inquest heard that the ASK MY GP system had been challenging for those involved with Mr Shearer and had made communication harder . The evidence identified that this was a particular issue for more vulnerable patients and their families .
” Is this part of a recurring concern? No recurring-concern membership is currently published.
Open source report
×
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 Establish which patients use digital systems and which do not, then share resulting learning with Trafford practices to reduce digital-access inequalities.
Verbatim wording from the response “During May 2021 the CCG also undertook a review of the patient experience of AskmyGP and 90% of the patients who had used the system were highly satisfied with it. With this said we are also currently undertaking a piece of work to establish who is using the digital systems, and more importantly who isn’t? This will enable us to reduce the inequalities in digital access across the borough. We will ensure that any learning is shared with our practices as part of this work.” Source location Response from Tafford Clinical Commissioning Group
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 Monitor equitable access to GP practices through the Primary Care Health Inequalities Quality Aims plan.
Verbatim wording from the response “As I mentioned earlier the CCG is not responsible for the monitoring of how our practices operate their systems, however we are responsible for ensuring our GP practices are offering high quality care including equal access across the borough and support for those without digital access. This is something we will continue to monitor via our current Primary Care Health Inequalities Quality Aims plan. This plan has been in place since November 2020 and improving access to our GP practices is an ongoing theme within this.” Source location Response from Tafford Clinical Commissioning Group
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 Share the Regulation 28 notice and related responses with more than 400 Trafford primary-care staff through the Practice Briefing.
Verbatim wording from the response “This extremely sad case has highlighted a number of issues that can occur in healthcare systems and processes where a vulnerable patient may be at risk of a delay in treatment. This report gives us a real example to use in reminding all GPs in Trafford about those risks, what clinicians should be considering in terms of their own practice systems and the resources available to support clinicians in the management of vulnerable patients with complex needs. Over the next week, we will be sharing a copy of the Regulation 28 along with the responses to this in our “Practice Briefing”, an email update which is sent out to over 400 Primary Care staff in Trafford twice a week.” Source location Response from Tafford Clinical Commissioning Group
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 Use quarterly educational events to disseminate system changes and learning from safety events to Trafford practice staff.
Verbatim wording from the response “The practice Medicines Management Team are also supporting this work to help avoid any unnecessary delays in a patient’s medication. As a CCG we offer support with EMISWeb system to develop system alerts as well as other system capabilities and all our practices have had the training to be able to manage this system on a day to day basis. Whilst we are not responsible for the monitoring of the operational systems of our practices, we use our quarterly educational events which practice staff attend to share any changes to the system and share learning from events such as this. We are really pleased that the practice is undertaking this exercise to ensure that patients with specific needs are managed appropriately.” Source location Response from Tafford Clinical Commissioning Group
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 Review patient experience of AskmyGP to assess satisfaction and identify access concerns.
Verbatim wording from the response “During May 2021 the CCG also undertook a review of the patient experience of AskmyGP and 90% of the patients who had used the system were highly satisfied with it. With this said we are also currently undertaking a piece of work to establish who is using the digital systems, and more importantly who isn’t? This will enable us to reduce the inequalities in digital access across the borough. We will ensure that any learning is shared with our practices as part of this work.” Source location Response from Tafford Clinical Commissioning Group
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 Assess the feasibility of a qualitative survey investigating patients’ experiences of requesting home visits.
Verbatim wording from the response “We are currently looking at the feasibility of conducting a qualitative survey to investigate the experience of patients who have requested home visits. Once we have developed an appropriate questionnaire, our plan is to conduct this study over the next 3 to 6 months.” Source location Response from North Trafford Group Practice
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 Review systems for recording and prioritising consultation and home-visit requests.
Verbatim wording from the response “We acknowledge the frustrations that the family of Mr Shearer experienced in trying to arrange a home visit. We have reviewed our systems to make sure they are appropriately robust with respect to recording and prioritising of requests for consultations and home visits. It appears in the case of Mr Shearer there was a failure to record the family’s request in the system for a home visit on 17 August 2021. We have reminded all reception staff of the importance of properly recording all requests for home visits in the clinical system so they are referred to clinicians for assessment. This requirement will be reinforced by the office manager in orientation and training sessions for reception staff.” Source location Response from North Trafford Group Practice
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 Implement patient-record alerts identifying patients who may have difficulty swallowing medication.
Verbatim wording from the response “The Practice has now adopted the policy of adding alerts to all patients who could have difficulty swallowing medication.” Source location Response from North Trafford Group Practice
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 workflow staff to enter swallowing-related codes and alerts when hospital correspondence identifies changes in a patient’s swallowing ability.
Verbatim wording from the response “When a hospital letter comes through indicating any changes in the patient’s ability to swallow, our workflow team will be trained to enter the codes and alerts as appropriate. Our medicines management team will be conducting searches on a monthly basis to ensure the appropriate alerts are in place. We will review this process after the first 3 months.” Source location Response from North Trafford Group Practice
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 Implement patient-record alerts identifying vulnerable patients or those needing support to access digital consultations.
Verbatim wording from the response “As mentioned earlier, the EMISWeb system allows us to put alerts on patients records to indicate when they are more vulnerable or if they struggle to use digital access. In response to the concern, we are in the process of putting these alerts in the system for relevant patients. We are hoping to complete this process over the next 4 weeks. This will help by alerting our staff that the patient may need extra support when requesting a consultation, or have specific requirements for the consultation such as an interpreter. This process has been discussed at practice meetings and is part of our call handling protocol.” Source location Response from North Trafford Group Practice
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 Reinforce home-visit request recording requirements through reception staff orientation and training.
Verbatim wording from the response “We acknowledge the frustrations that the family of Mr Shearer experienced in trying to arrange a home visit. We have reviewed our systems to make sure they are appropriately robust with respect to recording and prioritising of requests for consultations and home visits. It appears in the case of Mr Shearer there was a failure to record the family’s request in the system for a home visit on 17 August 2021. We have reminded all reception staff of the importance of properly recording all requests for home visits in the clinical system so they are referred to clinicians for assessment. This requirement will be reinforced by the office manager in orientation and training sessions for reception staff.” Source location Response from North Trafford Group Practice
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 Disseminate the swallowing-medication alert learning to practice staff and discuss the process at the next clinical meeting.
Verbatim wording from the response “In addition to the above system changes, we have also discussed this matter as a learning event within the senior team at the practice, and will be disseminating the learning from this. We will also have a further discussion in our next clinical meeting so that the clinical staff are aware of the new flagging process and how to enter the clinical codes and alerts in the EMISWeb system.” Source location Response from North Trafford Group Practice
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 Reiterate to clinical staff that clinicians must remain with patients after calling 999 until ambulance arrival and handover to the first responder.
Verbatim wording from the response “With respect to the calling of 999 for an urgent ambulance for Mr Shearer, it has been reiterated to all clinical staff that upon calling 999, the clinician must remain with the patient until the arrival of the ambulance and until handed over to the first responder.” Source location Response from North Trafford Group Practice
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 Discuss learning about AskMyGP and patient access at the next Patient Participation Group meeting.
Verbatim wording from the response “We have discussed patient access and the use of the AskMyGP system at our Patient Participation Group (PPG) meetings on several occasions. We have received good feedback overall about the system. However, we will also discuss the learnings from this recommendation at our next PPG meeting. One of our PPG members sits on Healthwatch Trafford, and one is a carer but registered at another practice. They both provide valuable insight into how they find using the AskMyGP system and we will take on board any further suggestions they may also have.” Source location Response from North Trafford Group Practice
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 Remind reception staff to record every home-visit request in the clinical system for clinician assessment.
Verbatim wording from the response “We acknowledge the frustrations that the family of Mr Shearer experienced in trying to arrange a home visit. We have reviewed our systems to make sure they are appropriately robust with respect to recording and prioritising of requests for consultations and home visits. It appears in the case of Mr Shearer there was a failure to record the family’s request in the system for a home visit on 17 August 2021. We have reminded all reception staff of the importance of properly recording all requests for home visits in the clinical system so they are referred to clinicians for assessment. This requirement will be reinforced by the office manager in orientation and training sessions for reception staff.” Source location Response from North Trafford Group Practice
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 Review the balance between remote and face-to-face consultations across Greater Manchester general practices.
Verbatim wording from the response “• In October 2021, NHS England set out a plan for improving access for patients and supporting general practice. This sets out how we will increase and optimise capacity, address variation, encourage good practice, and improve access, including face-to-face appointments with GPs.” Source location Response from NHS Greater Manchester
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 Progress the Greater Manchester access action plan to increase general-practice capacity and appointments, expand face-to-face GP access, reduce avoidable demand, and improve healthcare inequalities.
Verbatim wording from the response “• Greater Manchester integrated care system has completed an action plan with further steps to support improved access and address healthcare inequalities. The plan includes how each of our 10 local systems will tackle variation in general practice, which is our utmost priority. This will continue to be progressed following the establishment of NHS Greater Manchester Integrated Care and the closure of local clinical commissioning groups on 1 July:” Source location Response from NHS Greater Manchester
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 Work with digital and GP service providers to ensure technologies accommodate digitally excluded people and patients with complex conditions.
Verbatim wording from the response “We acknowledge that those with the greatest health needs are sometimes also the most at risk of being left behind by the ability to access, manage and contribute to digital tools, information and services. We continue to work with our digital and GP service providers to ensure these technologies work for everyone, from the most digitally literate to the most technology averse, and that they reflect the needs of people trying to stay healthy, as well as those with complex conditions.” Source location Response from NHS Greater Manchester
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 Identify and promote digital technologies that address patient-safety challenges.
Verbatim wording from the response “• Identify, and promote the use of, digital technologies as solutions to patient safety challenges.” Source location Response from NHS Greater Manchester
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 Develop digital clinical safety training materials and expand workforce access to the training.
Verbatim wording from the response “• Develop new digital clinical safety training materials and expand access to training across the health and care workforce.” Source location Response from NHS Greater Manchester
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 Present and share case learning with the Greater Manchester System Quality Group.
Verbatim wording from the response “• Learning to be presented/shared with the Greater Manchester System Quality Group. This meeting is attended by commissioners, including commissioners of specialist services, regulators, Healthwatch, local authority representatives and NICE.” Source location Response from NHS Greater Manchester
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 Create a centralised source of digital clinical safety information, including standards, guidelines and best-practice blueprints.
Verbatim wording from the response “• Create a centralised source of digital clinical safety information, including optimised standards, guidelines, and best practice blueprints.” Source location Response from NHS Greater Manchester
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 Reiterate standardised medication-requirement recording and safety-netting requirements in prescribing protocols, particularly when patients are not seen face-to-face.
Verbatim wording from the response “To share the learning from this case we will also reiterate the importance of standardised and consistent recording of medication requirements on the patient record, and ensuring that protocols for prescribing, particularly when the patient has not been seen face-to-face by the practice, include a safety netting element.” Source location Response from NHS Greater Manchester
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 Monitor key learning points and recommendations to ensure they become embedded in practice.
Verbatim wording from the response “GMHSCP is committed to improving outcomes for the population of Greater Manchester. Key learning points and recommendations will be monitored to ensure they are embedded within practice.” Source location Response from NHS Greater Manchester
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Monitoring how GP practices operate their systems is outside the CCG’s responsibility.
Verbatim wording from the response “The practice Medicines Management Team are also supporting this work to help avoid any unnecessary delays in a patient’s medication. As a CCG we offer support with EMISWeb system to develop system alerts as well as other system capabilities and all our practices have had the training to be able to manage this system on a day to day basis. Whilst we are not responsible for the monitoring of the operational systems of our practices, we use our quarterly educational events which practice staff attend to share any changes to the system and share learning from events such as this. We are really pleased that the practice is undertaking this exercise to ensure that patients with specific needs are managed appropriately.” Source location Response from Tafford Clinical Commissioning Group
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing digital systems provide clinician-triaged access to telephone, video, face-to-face consultations or home visits, with alternatives for patients unable to use them.
Verbatim wording from the response “The adoption of AskmyGP during 2020 was planned as part of the NHS Long Term Plan to improve digital access for patients. This was expedited during the COVID-19 pandemic due to the advantages it offered in remote working. 70% of our practices in Trafford use this system which has enabled patients to access their practice without the need to physically attend on site which was encouraged during the pandemic where possible. The remaining 30% of our practices use similar digital systems with the same capabilities. These digital systems do not mean that that face to face appointments are not available. Each request on these systems are reviewed by a clinician and a decision is made on the method of consultation, which could be by telephone, email, video consultation, face to face or a home visit.” Source location Response from Tafford Clinical Commissioning Group
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation CQC and NHS England will make required improvements across practices that do not meet patients’ reasonable needs.
Verbatim wording from the response “Alongside this we are also working with the Care Quality Commission (CQC), which will work with NHS England to support systems in this process and to make the required improvements across those practices which are not meeting reasonable needs of patients. The CQC is rapidly developing an inspection methodology with a particular focus on access to GP services.” Source location Response from NHS Greater Manchester
Open published response
Pin
Get email alerts
Request correction
Information checked against the published report and official responses