PFD report

Audrey Wakefield · Prevention of Future Deaths report

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Issued 22 Apr 2014•Staffordshire 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
5

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. Failure to ensure effective communication of discharge information to GPs at practices outside the Stoke on Trent area
    Part of recurring concern: Unreliable multi-agency communication procedures
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.4

  1. Action

    Continue negotiating annual funding arrangements with external GP practices and request confirmation of payment for electronic correspondence.

    Stated by University Hospitals of North Midlands NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 22 April 2014.
  2. Action

    Develop a supplier solution enabling electronic discharge correspondence for GP practices beyond Stoke and North Staffordshire.

    Stated by University Hospitals of North Midlands NHS TrustStated completedThe respondent said that this action was complete when they made their response on 22 April 2014.
  3. Action

    Switch on electronic discharge correspondence for GP practices in Stone, including the deceased’s practice.

    Stated by University Hospitals of North Midlands NHS TrustStated completedThe respondent said that this action was complete when they made their response on 22 April 2014.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.3

  1. Position

    Electronic rollout beyond existing areas cannot be completed until participating areas confirm funding for annual practice charges.

    Stated by University Hospitals of North Midlands NHS TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.

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 ensure effective communication of discharge information to GPs at practices outside the Stoke on Trent area

Wider context from the report

“(1) At the Inquest I was greatly assisted by ████████ Consultant Stroke 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 a good communication system from the hospital and 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 being taken to improve this. With Stafford Hospital moving to come under the 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 I should be grateful if you could check that an effective system of discharge information will apply wherever a patient’s GP’s practice may be situated. ”

Is this part of a recurring concern?

Yes — Unreliable multi-agency communication procedures.

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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

Continue negotiating annual funding arrangements with external GP practices and request confirmation of payment for electronic correspondence.

Verbatim wording from the response

“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 a requirement for each GP practice to pay an annual fee for the on-going delivery of electronic 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.”

Source location

2014-0186-Response-by-University-Hospital-of-North-Staffordshire
Page 2 · response
Published 22 April 2014

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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

Develop a supplier solution enabling electronic discharge correspondence for GP practices beyond Stoke and North Staffordshire.

Verbatim wording from the response

“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 a requirement for each GP practice to pay an annual fee for the on-going delivery of electronic 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.”

Source location

2014-0186-Response-by-University-Hospital-of-North-Staffordshire
Page 2 · response
Published 22 April 2014

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

Switch on electronic discharge correspondence for GP practices in Stone, including the deceased’s practice.

Verbatim wording from the response

“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 being 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 1 November 2014.”

Source location

2014-0186-Response-by-University-Hospital-of-North-Staffordshire
Page 2 · response
Published 22 April 2014

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

Switch on electronic discharge correspondence for remaining Stafford and Cannock GP practices by the end of July 2014.

Verbatim wording from the response

“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 being 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 1 November 2014.”

Source location

2014-0186-Response-by-University-Hospital-of-North-Staffordshire
Page 2 · response
Published 22 April 2014

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

Electronic rollout beyond existing areas cannot be completed until participating areas confirm funding for annual practice charges.

Verbatim wording from the response

“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 I wrote to them on 29 April 2014. This will include remote implementation and training where possible, and GP practices will also be supported by a 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. I 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.”

Source location

2014-0186-Response-by-University-Hospital-of-North-Staffordshire
Page 2 · response
Published 22 April 2014

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

Ongoing electronic correspondence costs are expected to be funded by GP practices or their local Clinical Commissioning Groups.

Verbatim wording from the response

“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 a requirement for each GP practice to pay an annual fee for the on-going delivery of electronic 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.”

Source location

2014-0186-Response-by-University-Hospital-of-North-Staffordshire
Page 2 · response
Published 22 April 2014

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

Delivery of discharge-information improvements is a shared responsibility involving the Local Health Economy IM&T Group and Clinical Commissioning Groups.

Verbatim wording from the response

“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.”

Source location

2014-0186-Response-by-University-Hospital-of-North-Staffordshire
Page 2 · response
Published 22 April 2014

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

    Operate electronic clinical correspondence across Stoke and North Staffordshire GP practices to deliver discharge letters electronically.

    Stated by University Hospitals of North Midlands NHS TrustStated completedThe respondent said that this action was complete when they made their response on 22 April 2014.

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 electronic clinical correspondence across Stoke and North Staffordshire GP practices to deliver discharge letters electronically.

Verbatim wording from the response

“1. 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.”

Source location

2014-0186-Response-by-University-Hospital-of-North-Staffordshire
Page 2 · response
Published 22 April 2014

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