Prevention of Future Deaths reports · 2013
Regulation 28 report to prevent future deaths, reference 2013-0241, written 25 Sep 2013. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 25 Sep 2013 |
|---|---|
| Reference | 2013-0241 |
| Deceased | Amna Umer Ahmed |
| Coroner | Andrew Harris |
| Coroner area | London Inner (South) |
| Category | Community Healthcare Death |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Hon. Secretary of the Royal College of General Practitioners Royal College of General Practioners 30 Euston Square London NW1 2FB 2. President, British Cardiovascular Society 9 Fitzroy Square, London, W1T 5HW CORONER | am Andrew Harris, Senior Coroner, London Inner South CORONER’S LEGAL POWERS | make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. [HYPERLINKS] INVESTIGATION and INQUEST On 12.10.11 | opened an inquest into the death of Amna Umer Ahmed, aged 30, dod 10" October 2011, case ref 02631-2011. The inquest was heard on 18" September 2013. The conclusion of the inquest was natural causes. CIRCUMSTANCES OF THE DEATH Mrs Ahmed, aged 30, with a family history of heart disease, was seen by ambulance staff with chest pain and examination and ECG were reported as normal. The officers were aware of and considered sudden adult death syndrome. She needed medical assessment and chose to go later to her GP for further investigation. He concluded that the pain was non cardiac, but referred her for an appointment in a chest pain clinic. She died sudden adult cardiac death syndrome (SAD) a few hours later at home. CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. The GP had not considered the possibility of sudden adult cardiac death syndrome, which is rare but afflicts young people and may be inherited. The mechanism of death is often an arrhythmia, which is difficult to diagnose but a specialist needs to examine the QT interval on the ECG and a 24 tape is often indicated. He did not order a Troponin test or full ECG or refer urgently to hospital and did not know under what circumstances he should do so. He knew of no guidance available to GPs. In my opinion there is a risk that future deaths will occur unless action is taken to increase awareness of this condition and the circumstances in which young people with chest pain or dizziness should be urgently referred. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. — (1) Possibility of generally low awareness of the condition of SAD in general practice (2) Apparent lack of guidelines or lack of awareness of guidelines available to guide GPs on the circumstances for urgent referral of patients who should be suspected as being vulnerable to SAD. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe the Royal College of Practitioners, if appropriate in conjunction with the British Cardiovascular Society, have the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by November 19" 2043. |, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons: EE oryiow Heath Centre | have also sent it to LAS who may find it useful or of interest. lam also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. DATE : SIGNED BY CORONER’ pre 2S Syke 3
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
G P General Practitioners Professor Nigel Mathers FRCGP Honorary Secretary Mr Andrew Harris Coroner for the Inner Southern District of Greater London Borough of Southwark The Coroner's Court 1 Tennis Street London SEi 1YD 15 January 2014 Dear Ms Kearsley Regulation 28 report to prevent future deaths — Mrs Amna Umer Ahmed (deceased) Thank you for your letter addressed to the College Treasurer, which has been passed to me for response as Honorary Secretary as | have responsibility for responding to requests from coroners. | apologise profusely for the delay in responding to your request which is due to a changeover in staffing responsibilities within the organisation. On behalf of the College, | set out below a brief description of the remit of the Royal College of General Practitioners and comments on the specific concerns you raise in your report with regard to general practitioners: possibility of generally low awareness of the condition of Sudden Adult Cardiac Death in general practice and apparent lack of awareness of guidelines available to guide GPs on circumstances for urgent referral of patients who might be suspected as being at risk. The role of the College The Royal College of General Practitioners is a registered charity under Royal Charter and is the largest membership organisation in the United Kingdom solely for GPs. Founded in 1952, it has over 44,000 members who are committed to improving patient care, developing their own skills and promoting general practice as a discipline. We are an independent professional body with enormous expertise in patient-centred generalist clinical care. Through our General Practice Foundation, established by the RCGP in 2009, we also maintain close links with other professionals working in General Practice, such as practice managers, practice nurses and physician assistants. As well as running the postgraduate Membership examination (MRCGP) which is now required for doctors to qualify as GPs, the College also provides continuing professional development (CPD) for its members, and these continuing programmes are also available to non-members of the College. However, not all GPs are members of the College, and older GPs may never have joined. The General Medical Council holds the register of all who are considered able to practise as GPs, and it is to the GMC that revalidated doctors will be notified.. Similarly, it is not for us to comment on the performance of any individual GP and the information set out below is solely to show you what we do in the context of training and advice to our Members. Royal Cellege of General Practitioners 30 Euston Square Londen NW1 2FB Tel 020 3188 7400 Fax 020 3188 7401 Email info@regp.erg.uk Web www.regp.erg.uk Patren: His Reyal Highness the Duke ef Edinburgh Registered charity number 223106 Coroner's concerns on low awareness amongst GPs of SAD and apparent lack of guidelines for GPs on management of at risk patients Currently all doctors wishing to follow a career in general practice in the UK are required to undergo a 3 year programme of vocational training for general practice, based on the College’s GP Curriculum. (The curriculum forms the foundation for GP training and assessment across the UK, prior to taking the College’s Membership Examination (MRCGP) and is relevant to GPs throughout their career, including preparation for revalidation) http://Awww.fegp.org.uk/gp-training-and-exams/gp-curriculum-overview. aspx Cardiovascular disease is extensively covered in the Curriculum. Parts of j Statement 15.1 Cardiovascular disease in Primary Care: a guide for GPs. iii , are particularly relevant in this case namely: - The section on family history from ch.2 Prevention of cardiovascular disease, and related reference list - Chapter 6 'Cardiac arrhythmias' which diagnosis of arrhythmia (mentioned in your report) - Chapter 11 ‘Emergency care' covers diagnosis/further treatment of patients presenting with relevant symptoms. Photocopies of these sections of the Curriculum are attached for ease of reference. More generally, other sources of guidance about Sudden Adult Cardiac Death syndrome are to be found on the website of the British Heart Foundation (which aims to provide help to both patients and their families and to healthcare professionals) http://www.bhf.org.uk/publications/publications-search- results.aspx?m=simple&q=Suddentadulttcardiac+death+syndrome and the European Guidelines on cardiovascular disease prevention in clinical practice (version 2012) - available online: htto://www.escardio.org/quidelines-surveys/esc-guidelines/Pages/cvd-prevention.aspx We would support your suggestion of the need for joint working on raising awareness amongst GPs of Sudden Adult Cardi with the appropriate specialist primary care society and have consulted the Medical Director of the British Heart Foundation, an active College member, for his thoughts. As yet no response has been received. | will forward a copy of the response from the BHF as soon as | receive it. Meanwhile, | hope you find these comments helpful. Reyal Cellege of General Practitioners 30 Euston Square Londen NW 2F8 Tel 020 3188 7400 Fax 020 3188 7401 Email info@regp.org.uk Web www.regp.org.uk Patron: His Reyal Highness the Duke ef Edinburgh Registered charity number 223106
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