Prevention of Future Deaths reports · 2013
Regulation 28 report to prevent future deaths, reference 2013-0275, written 23 Oct 2013. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 23 Oct 2013 |
|---|---|
| Reference | 2013-0275 |
| Deceased | Jacqueline Allwood |
| Coroner | Andrew Harris |
| Coroner area | London Inner (South) |
| Category | Community health care · Emergency Services related deaths |
| 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. ee: & ER chief Accountable Officer
Bromley Clinical Commissioning Group
2. a «i. Executive Bromley Healthcare / Beckenham
eacons
3. The GP Partners, Cator Medical Centre
4, PE 0 2s::c2100n Manager, Fitness to Practice Team,
eneral Medical Council
CORONER
| am Andrew Harris, senior coroner for the jurisdiction of London Inner South
re
[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.
INVESTIGATION and INQUEST
On 24.01.12 | opened an inquest into the death of Jacqueline Allwood, case ref
126/12, aged 47, dod 14" January 2012. The inquest was heard on 7" October 2013,
The conclusion of the inquest was given by a narrative verdict:
Mrs Aliwood attended Cator Medical Centre where she saw a GP on Tuesday 37
January 2012, limping with several days of calf pain. She received a brief examination
and was given advice and a diagnosis of musculoskeletal pain. Failure to take an
adequate history (which would have elicited a strong family history of thrombosis) and
failure to refer to Accident and Emergency Department to exclude a possible Deep Vein
Thrombosis (DVT) amounted to neglect. Death occurred at 01.25 on 14/1 at Lewisham
Hospital, having collapsed at home with unsuccessful emergency resuscitation. Death
was caused by pulmonary thromboembolism secondary to a DVT, which would have
been preventable if she had been referred to hospital on 3 January.
CIRCUMSTANCES OF THE DEATH
1, Circumstances related to presentation to the Urgent Care Centre
The patient attended the Urgent Care Centre, Beckenham Beacons having awoken with
calf pain three or four days previously. Her daughter says that she filled in a registration
form and was then asked to go round to the general practice as she had not injured
herself, where there was a service of direct access to patients of any practice, by
agreement with the Urgent Care Centre. An urgent care centre registration form was
inspected and other than demographic or contact details only requested information
about “reason for visit today”. The GP receptionist advised that there would be a two
hour wait and entered the reason for visit under “Reported condition” as pain in right calf.
The GP did not see the UCC registration form, advised that the information from it may
Or may not be entered on the computer system, and would be shredded. He gave
evidence that he did not see the section in his practice’s electronic record that requests
medications and past history, but it was blank in this instance, as it often was.
The A&E expert, [NII gave evidence that patients presenting to an urgent care
centre, walk in centre or out of hours are a much higher risk group than those who
present to their own GP surgery. As a consequence, his statement continued, there
must be clinically agreed protocols at the front end of any facility that receives
undifferentiated patients that manage this higher risk population. Patients that present
with certain high risk conditions such as chest pain, shortness of breath or calf pain must
be directed to a facility that can exclude serious illness and this is usually the nearest
Accident & Emergency Department.
A witness from the UCC provided evidence of the UrgentCare Pathway and Reception
Streaming Assessment form, which does not remember her mother
completing. It identifies several serious conditions or symptoms, but not including calf
pain or DVT.
The GP, supported by the GP expert, gave evidence that the risk of
missing a diagnosis of possible DVT would be reduced, especially for busy GPs, if the
patient could be asked to list past medical history, family history and medication, and to
hand the form to the doctor at the start of the consultation.
2. Circumstances related to the consulting GP:
The GP was informed that the patient attended due to fear of having a DVT in view of
family history. He considered DVT as a possible diagnosis but did not enquire further
and so did not discover that four and possibly five members of the family had suffered
from thromboembolism. The GP expert witness, EEE said that ascribing the
pain to a history of getting decorations from the attic was insufficient to conclude as an
alternative cause of pain when she reported no pain at the time. There was no record of
the risk factors that were considered in this case other than no swelling. A daughter who
accompanied the patient to the GP said that he concluded that there could not be a DVT
as the calf would need to be severely swollen. Whilst the GP denied he said this, |
accepted on the balance of probabilities the evidence of the daughter.
The GP expert said that the patient should have been referred to hospital solely on the
basis of the history. He identified a third failure, which did not contribute to death, which
was the failure to examine the patient adequately to assess the risk of DVT. The GP
examined the legs whilst the patient was sitting with her shoes on and trousers rolled
up. He only felt the painful calf and informed the court that visual inspection in this
position was sufficient to determine whether there was difference of more than 3cm (a
threshold for the Weils test) or whether there was ankle oedema.
The GP expert gave an opinion that this was an inadequate examination and that the
patient should be lying on the couch with trousers off and both legs examined on both
sides under a light. Expert advice of a GP confirmed that the threshold for referral was
possible risk of DVT and that was met here and she should have been referred. Expert
opinion evidence from an A&E consultant, Dr Metcalfe, confirmed that death would
have been prevented if referred on 3" as the patient would have been anticoagulated.
CORONER’S CONCERNS
During the course of the inquest the evidence revealed matters giving rise to concern.
1. Attendance at the Urgent care centre with or without referral to the adjacent general
practice does not apparently have, as advised by an A&E expert, an agreed protocol for
management of calf pain and suspected DVT. Evidence was heard that DVT isa
relatively common condition, but missing the diagnosis is potentially catastrophic.
2. The GP expert gave evidence that there was an on going risk of future deaths of
patients from undiagnosed DVT, in the light of the GP’s training needs and said that the
GP should review his practice. He advised that the coroner should consider referral to
the GMC.
The GP was asked if his examination of a patient with a suspected DVT would be any
different now and he said no, apart from measurement of the calves. “to make sure that
I'm not here again”. Having heard the evidence of the GP expert, he said that he had
had two discussions with his appraiser and there had been no actions which indicated
that he needed further training. He also said that he had not made anyone lie on the
couch in examinations since, but had referred more patients to hospital. To questioning
he then agreed that taking shoes off was a good idea and that he wouid lie the patient
on a couch in future. The GP expert said despite changes he had made, it would be
reassuring to have further evidence about his practice and not just this situation.
The MATTERS OF CONCERN are as follows. —
(1) The registration, assessment and referral forms and consultation records of and
between the Urgent Care Centre and Cator Medical Practice may not facilitate the early
diagnosis of DVT and the need for a low threshold of referral to A&E.
(2). Taking as a whole the evidence of the consulting GP, Jt cannot be said
that the public can be assured that he understands and accepts normative standards of
practice with respect to history and examination and that he has made or will make
changes in order to reduce risks of harm to patients.
4
ACTION SHOULD BE TAKEN
(1) Bromley Clinical Commissioning Group, Bromley Health Care/ Beckenham
Beacons Urgent Care Centre and Cator Medical Centre are asked to consider Matter of
Concern (1) above and the recommendation of the expert GP about patients recording
medication, PMH and FH in documentary form prior to seeing the doctor.
(2) The General Medical Council are asked to regard this report as a referral to their
fitness to practice team, consider Matter of Concern (2) and advise IWhether
a review of his practice or retraining is indicated.
{|
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report,
namely by 17" of December 2013. |, 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:
sister
daughter
GP
| have also sent it to:
HR anager Bromley Healthcare Trust
fF
expert Consultant in A&E
_ [BEES exert cP 4
Prof Amanda Howe, Secretary of Royal College of General Practitioners
Mr David Harrison, Public Health Policy and Strategy Unit, Department of Health, who
may find it useful or of interest.
| am 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.
If you would like further information about the case, please contact my officer, Miss
Lesley Brown, on 020 7525 0792, lesley.brown@southwark.gov.uk.
[DATE] [SIGNED BY CORONER
2iek tle a
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
Re: Jacqueline Allwood Dod: 14" January 2010, Case number: 126/12
Case Officer: Ms Lesley Brown, Tel no. 020 7 525 0792
THIS REPORT IS BEING SENT TO:
1. Dr Andrew Parson, Chair & Dr Angela Bhan Chief/Accountable Officer
NHS Bromley Clinical Commissioning Group
2. Mr Jonathan Lewis, Chief Executive Bromley Healthcare / Beckenham
Beacons UCC
3. The GP Partners, Cator Medical Centre
4, Ms Amanda Brown, Investigation Manager, Fitness to Practice Team,
General Medical Council
1 | CORONER
| am Andrew Harris, senior coroner for the jurisdiction of London Inner South
2 | 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.
a |
3 | INVESTIGATION and INQUEST
On 24.01.12 | opened an inquest into the death of Jacqueline Allwood, case ref
126/12, aged 47, dod 14" January 2012. The inquest was heard on 7" October 2013.
The conclusion of the inquest was given by a narrative verdict:
Mrs Allwood attended Cator Medical Centre where she saw a GP on Tuesday 3"
January 2012, limping with several days of calf pain. She received a brief examination
and was given advice and a diagnosis of musculoskeletal pain. Failure to take an
adequate history (which would have elicited a strong family history of thrombosis) and
failure to refer to Accident and Emergency Department to exclude a possible Deep Vein
Thrombosis (DVT) amounted to neglect. Death occurred at 01.25 on 14/1 at Lewisham
Hospital, having collapsed at home with unsuccessful emergency resuscitation. Death
was caused by pulmonary thromboembolism secondary to a DVT, which would have
been preventable if she had been referred to hospital on 3 January.
4 | CIRCUMSTANCES OF THE DEATH
1. Circumstances related to presentation to the Urgent Care Centre
The patient attended the Urgent Care Centre, Beckenham Beacons having awoken with
calf pain three or four days previously. Her daughter says that she filled in a registration
form and was then asked to go round to the general practice as she had not injured
herself, where there was a service of direct access to patients of any practice, by
agreement with the Urgent Care Centre. An urgent care centre registration form was
inspected and other than demographic or contact details only requested information
about “reason for visit today”. The GP receptionist advised that there would be a two
hour wait and entered the reason for visit under “Reported condition” as pain in right calf.
The GP did not see the UCC registration form, advised that the information from it may
or may not be entered on the computer system, and would be shredded. He gave
evidence that he did not see the section in his practice’s electronic record that requests
medications and past history, but it was blank in this instance, as it often was.
The A&E expert, Dr Metcalfe, gave evidence that patients presenting to an urgent care
centre, walk in centre or out of hours are a much higher risk group than those who
present to their own GP surgery. As a consequence, his statement continued, there
must be clinically agreed protocols at the front end of any facility that receives
undifferentiated patients that manage this higher risk population. Patients that present
with certain high risk conditions such as chest pain, shortness of breath or calf pain must
be directed to a facility that can exclude serious iliness and this is usually the nearest
Accident & Emergency Department.
Awitness from the UCC provided evidence of the UrgentCare Pathway and Reception
Streaming Assessment form, which Mrs Allwood does not remember her mother
completing. It identifies several serious conditions or symptoms, but not including calf
pain or DVT.
The GP, supported by the GP expert, Dr Harborow gave evidence that the risk of
missing a diagnosis of possible DVT would be reduced, especially for busy GPs, if the
patient could be asked to list past medical history, family history and medication, and to
hand the form to the doctor at the start of the consultation.
2, Circumstances related to the consulting GP:
The GP was informed that the patient attended due to fear of having a DVT in view of
family history. He considered DVT as a possible diagnosis but did not enquire further
and so did not discover that four and possibly five members of the family had suffered
from thromboembolism. The GP expert witness, Dr Harborow, said that ascribing the
pain to a history of getting decorations from the attic was insufficient to conclude as an
alternative cause of pain when she reported no pain at the time. There was no record of
the risk factors that were considered in this case other than no swelling. A daughter who
accompanied the patient to the GP said that he concluded that there could not be a DVT
as the caif would need to be severely swollen. Whilst the GP denied he said this, |
accepted on the balance of probabilities the evidence of the daughter.
The GP expert said that the patient should have been referred to hospital solely on the
basis of the history. He identified a third failure, which did not contribute to death, which
was the failure to examine the patient adequately to assess the risk of DVT. The GP
examined the legs whilst the patient was sitting with her shoes on and trousers rolled
up. He only felt the painful calf and informed the court that visual inspection in this
position was sufficient to determine whether there was difference of more than 3cm (a
threshold for the Wells test) or whether there was ankle oedema.
The GP expert gave an opinion that this was an inadequate examination and that the
patient should be lying on the couch with trousers off and both legs examined on both
sides under a light. Expert advice of a GP confirmed that the threshold for referral was
possible risk of DVT and that was met here and she should have been referred. Expert
opinion evidence from an A&E consultant, Dr Metcalfe, confirmed that death would
have been prevented if referred on 3 as the patient would have been anticoagulated.
CORONER’S CONCERNS
During the course of the inquest the evidence revealed matters giving rise to concern.
1. Attendance at the Urgent care centre with or without referral to the adjacent general
practice does not apparently have, as advised by an A&E expert, an agreed protocol for
management of calf pain and suspected DVT. Evidence was heard that DVT is a
relatively common condition, but missing the diagnosis is potentially catastrophic.
2. The GP expert gave evidence that there was an on going risk of future deaths of
patients from undiagnosed DVT, in the light of the GP’s training needs and said that the
GP should review his practice. He advised that the coroner should consider referral to
the GMC.
The GP was asked if his examination of a patient with a suspected DVT would be any
different now and he said no, apart from measurement of the calves. “to make sure that
I'm not here again”. Having heard the evidence of the GP expert, he said that he had
had two discussions with his appraiser and there had been no actions which indicated
that he needed further training. He also said that he had not made anyone lie on the
couch in examinations since, but had referred more patients to hospital. To questioning
he then agreed that taking shoes off was a good idea and that he would lie the patient
on a couch in future. The GP expert said despite changes he had made, it would be
reassuring to have further evidence about his practice and not just this situation.
The MATTERS OF CONCERN are as follows. —
(1) The registration, assessment and referral forms and consultation records of and
between the Urgent Care Centre and Cator Medical Practice may not facilitate the early
diagnosis of DVT and the need for a low threshold of referral to A&E.
(2). Taking as a whole the evidence of the consulting GP, Dr Adlakha, it cannot be said
that the public can be assured that he understands and accepts normative standards of
practice with respect to history and examination and that he has made or will make
changes in order to reduce risks of harm to patients.
6
ACTION SHOULD BE TAKEN
(1) Bromley Clinical Commissioning Group, Bromley Health Care/ Beckenham
Beacons Urgent Care Centre and Cator Medical Centre are asked to consider Matter of
Concern (1) above and the recommendation of the expert GP about patients recording
medication, PMH and FH in documentary form prior to seeing the doctor.
(2) The General Medica! Council are asked to regard this report as a referral to their
fitness to practice team, consider Matter of Concern (2) and advise Dr Adlakha whether
a review of his practice or retraining is indicated.
7
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report,
namely by 17" of December 2013. |, 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.
8
COPIES and PUBLICATION
| have sent a copy of my report to the Chief Coroner and to the following Interested
Persons:
Mrs Beverley Carpenter, sister
Ms Tanya Allwood, daughter
Dr Saurabh Adlakha, GP
I have also sent it to:
Mrs Fiona Christie, manager Bromley Healthcare Trust
Dr Stephen Metcalfe, expert Consultant in A&E
|__| Dr Patrick Harborow, expert GP
Prof Amanda Howe, Secretary of Roya! College of General Practitioners
Mr David Harrison, Public Health Policy and Strategy Unit, Department of Health, who
may find it useful or of interest.
[am 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.
If you would like further information about the case, please contact my officer, Miss
Lesley Brown, on 020 7525 0792, lesley.brown@southwark.gov.uk.
ol
[DATE] 23 tov [SIGNED BY ws a
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.
Your Ref: 1216/2
Private & Confidential
Dr Andrew Harris
Coroner for Inner South District
Greater London
Southwark Coroner's Court
1 Tennis Street
Southwark
SE1 1YD
31 March 2014
Dear Dr Harris
NHS
England
London Regional Team
Medical Directorate (South)
4th Floor, Southside
105 Victoria Street
London
SW1E 6QT
Re: Jacqueline Allwood (Deceased)
Firstly | would like to apologise for the delay in sending this to you.
This report is a response by NHS England to the concerns raised by the coroner
following an inquest into the death of Jacqueline Allwood, case ref 126/12.
The inquest was held on the 7" October 2013.
NHS England apologises for the delay in the submission of the report and are
grateful to the coroner for agreeing to extend the date by which this report is
submitted.
The General Medical Council (GMC) have requested a copy of this report. For this
reason a brief summary of the circumstances that gave cause for this inquest
enquiry is given.
Circumstances of the concern raised:
Mrs Allwood was 47 years old when she died of a pulmonary thromboembolism
secondary to a DVT on the 14"" January 2012. Eleven days prior to her death, on
the 3 January 2012, Mrs Allwood had presented to the Urgent Care Centre (UCC)
at Beckenham Beacon complaining of pain in right calf. She was triaged by the
UCC reception staff to the adjacent Cator Medical Centre where she consulted Dr
a GP who was on the South London Medical Performers List at
Page 1 of 9
the time. Wherfiiiessessed Mrs Allwood he came to the conclusion that
her symptoms were musculo-sketal in origin.
After investigating the circumstances pertaining to Mrs Allwoods death, the coroner
delivered a narrative verdict which stated that the failure o to take an
adequate history (which would have elicited a strong family history of thrombosis)
and failure to refer to Accident and Emergency department to exclude a possible
Deep Vein Thrombosis amounted to neglect. :
The coroner wrote a report under paragraph 7, Schedule 5 of the Coroners and
Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations)
Regulations 2013.
In this report the coroner identified two areas of concern that need to be addressed
further: :
* The processes between the Urgent Care Centre and Cator Medical Practice
need to be reviewed to ensure they facilitate the early diagnosis of a DVT and
the need for a low threshold of referral to A&E.
NHS England have made contact with the Urgent Care Centre at Beckenham
Beacon and Cator Medical Centre. It is understood that they have made
representation to the coroner in separate correspondence. They inform NHS
England that they have made amendments to the triage process and have
introduced a new screening form to highlight medical and family histories.
e Assurance that I understands and accepts normative standards of
practice with respect to the history and examination and that he has made or
will make changes in order to reduce the risk of harm to patients
This report will concentrate on this area of concern.
1. Sources of evidence reviewed by NHS England
NHS England has gathered evidence from various sources which will be
described. As a result of this information gathering, the author has proposed an
action plan which is intended to ensure that A 2s reviewed and
changed his practice.
Page 2 of 9
1.1. NHS England meeting with Dr Adlakha on 10" October 2013.
HEE sought this meeting with NHS England immediately following the
Inquest on the 7" October 2013. This was thought to be indicative of how
seriously Dr Adlakha had taken the severe criticism that he had received at the
Inquest.
At the meeting [J summarised his career and experience in much the
same way as he had done at the Inquest hearing. He qualified as doctor in
2003 in India and passed the PLAB in the same year which allowed him to work
in the UK. He undertook GP training which he completed in 2007 when he
passed the MRCGP. He has a total of 12 months experience working in an
A&E setting and 6 years as a GP. He declared that he has not had any
previous serious complaints and in particular, to the best of his knowledge he
has not previously misdiagnosed a patient presenting with a DVT.
EEE escribed his recall of the consultation with Mrs Allwood on the 3%
January 2012. The patient had presented to the Urgent Care Centre and had
been assessed by a receptionist who had directed the patient to the adjacent
Cator Medical Centre to be seen by a doctor EE said that he saw the
patient promptly. The medical record suggested that it was a very short
consultation (4 minutes) but he thought that reflected the time he took to write
up the medical record rather than actually see the patient. Apparently the
daughter who accompanied Mrs Allwood confirmed at the Inquest that it was an
unhurried consultation.
HE t01¢. NHS England that Mrs Allwood had presented with a 4 day
history of pain in her right calf. He didn’t recall noticing her limping. He obtained
a history that she had undertaken an unusual activity for her in that she had
been moving heavy Christmas decorations. As a result of this history,
HE developed a working diagnosis that her symptoms were of musculo-
skeletal origin. He felt this hypothesis was supported by the fact that there
was no obvious swelling of the.leg when he examined her. [EEFecalls
giving Mrs Allwood advice on the conservative management of her symptoms.
a: NHS England how shocked he had been when he had learnt of
Mrs Allwoods untimely death 11 days later.
He recognised this as a very significant event in his professional career. Not
only had he been asked to write a report for the coroner but he had also been
in receipt of a complaint from Mrs Allwoods daughter’. had
declared this complaint in his appraisal evidence for the appraisal years 2011 —
2012 and 2012 -13. At his last appraisal on the 7" March 2013 this complaint
* He wrote in his appraisal documentation that Mrs Allwoods daughter had filed a civil case against him.
Page 3 of 9
1.2.
1.3.
was discussed and this appraisal documentation has been reviewed by NHS
England. HB wrote in his appraisal documentation:
‘it has affected my confidence as far as diagnosis of DVT’s is concerned. The
deceased had very low risk for DVT but still developed one and died
subsequently. | have to become more careful and vigilant about DVT’s and try
and refer to the Wells score when possible. Also | advise patients to monitor
their symptoms closely and of course go to A&E.’
During the appraisal discussion the complaint was discussed. a <2i:
that he had discussed the presentation with a number of colleagues. However
it was noted by NHS England that the knowledge gap that had been exposed
had not been included in his PDP.
At the meeting with NHS England, it was established that prior to the Inquest,
had not fully understood his vulnerability to criticism and as a result
he had not asked his defence organisation to accompany him to the Inquest’.
had also not expected the adverse media exposure, nor had he
considered the possibility of referral to the GMC which could ultimately put his
licence to practice at risk.
HEE attitude was respectful of the court process. He presented to
NHS England as a doctor who had been humbled by his very difficult
experience in the coroner’s court and who was keen to learn from his mistake
and perform to a higher standard in the future. He expressed a willingness to
engage in whatever remediation process was suggested.
Regulation 28 Report
This report was dated the 23 October2013 and NHS England has carefully
read this report, its conclusions and recommendations.
Court transcript
NHS England obtained a copy of the recorded court proceedings. The
intention was to listen to the evidence given by a: well as the
evidence given by the expert witnesses to ensure NHS England fully
understood the circumstances of Mrs Allwoods death and how the coroner
reached his conclusions. This would help NHS England develop an
appropriate action plan to ensurel understands and accepts the
expected standards of practice.
The author noted that at the inquest it was assumed that the DVT which
caused Mrs Allwoods untimely death must have been present at the time
when she presented to the Urgent Care Centre 11 days earlier. Mrs Allwood
? NHS England understands that he had contacted the MDDUS when he was first notified by the coroner of the
death of Mrs Allwood. He had sent his report to the MDDUS who had approved it.
Page 4of 9
did not attend her own GP or present again to the Urgent Care Centre during
the intervening 11 days.
The coroner had called two expert witnesses. PF who was
an expert consultant in A&E. HE presented evidence of the need for
clinically agreed protocols in the Urgent Care setting, as he observed that
patients who present to an urgent care facility are generally a higher risk
group.
The second expert witness was Ee ih was called as an
expert GP. The coroner declared that the expert GP was personally known to
him, having been colleagues in General Practice some years ago. The
coroner declared that there was no conflict of interest as nowadays they see
each other infrequently. At the time of the inquest, HE was working
in the Urgent Care Centre attached to St Thomas's Hospital.
was asked to comment specifically on HMB history taking, the
examination undertaken, the management plan and the safety netting.
1.4. Acopy of the medical record
NHS England obtained a copy of the medical record written on the 3” January
when Mrs Allwood presented at the Urgent Care Centre.
A transcript is recorded here for completeness sake.
Reported condition:
Symptoms: pain in right calf®
Consultation details:
History:
Dull, aching pain in the rt calf since 4/7. No recent trauma or sob. No swelling in the
leg.
Examination:
Right calf appears normal. Minimal tenderness in the rt calf.
Diagnosis:
Musculoskeletal pain
Treatment:
Reassured, rest and ice the area and use ibuprofen prn and see. Review with gp
prn.
3 This would have been recorded by the receptionist when the patient first presented to the service
Page 5 0f 9
2. Assessment of the medical performance of EE com which the
Action Plan is drawn.
HE acknowledged that this case had changed his practice and that he
was now much more cautious when presented with a patient complaining of calf
pain. However he has yet to present strong evidence of the change in his
professional practice that occurred following this case.
The case raises issues that NHS England would expect to see evidence that |_|
MEE has either researched or reflected further upon, and considered more
fully on how he might change his practice.
2.1. NHS England considers that medical record keeping fell below the
standard expected. He did not record the mechanism of injury/stress that he
had obtained from the history he took and from which he surmised that Mrs
Allwoods presentation was related to a musculo-skeletal problem.
also failed to safety net adequately. NHS England will expect to
attend a course on medical record keeping by no later than 30" June 2014.
Following this, ii be requested to undertake an audit of his
consultations against the criteria set by the IMAP* process and submit the
outcome to NHS England by no later than 28" July 2014 of the course.
2.2. NHS England expect li to demonstrate that he has considered the
comments from the expert witness who felt that a mark of good practice would
be to have calculated the Wells score. [J observes that following
this case, he is now more likely to calculate the Wells score. In this particular
case, Mrs Allwood would probably have scored less than 2 which would
suggest to the doctor that a DVT was ‘unlikely’. NHS England expects
a. reflect on the validity of the Wells score and how he plans to
incorporate it into his day to day practice.
2.3. [EEE did not record a family history in his medical record and does not
recall actively seeking the history. Mrs Allwood’s daughter recalls telling Ii
GD that they had a family history of DVT’s®. The coroner placed great
importance on this history and felt that it probably outweighed all other
evidence. NHS England would like to see evidence that HEMhas given
* IMAP ~ interim Membership by Assessement of Performance (RCGP)
The Wells score is thought to be a useful score to assess the probability of a patient having a DVT or not.
6 lt is noted that the family history was not recorded in the GP held medical record. The court transcript dees not record when the family came to realise that there was
such a strong familial pattern, although there is an assumption this was known before Mrs Allwoods death.
Page 6 of 9
2.4.
2.5.
greater consideration to this view and researched the genetic influence on the
risk of venous thromboembolic disease.
HE vas criticised for his incomplete examination of Mrs Allwoods leg.
GEE was surprised that the expert GP witness stated that all patients
with a painful calf should remove their lower clothing (except for underwear)
and be examined in the prone and supine position on the examination couch.
HE dic not feel this was common GP practice and wasn’t sure that all
patients would accept this exposure in a GP surgery situation. However he
accepted that he should have removed Mrs Allwoods shoes and socks so he
had full exposure of Mrs Allwoods lower leg. He also accepts that he should
have measured the calf diameter, if for no other reason than to be helpful
should the patient present for a second time and this first measurement could
be used as a comparator’. NHS England would like to see evidence that
GE has sought advice from other GP’s as to how they examine the leg in a
similar situation and has come to a considered opinion as to how he will go
about such an examination in the future.
The GP expert witness alluded to the daily challenge of General Practice
whereby the GP has to constantly weigh the balance of probability in the cases
they see. GP’s can find themselves criticised for unnecessary referrals
especially when they are being overly cautious and yet when they get it
wrong, the criticism and censure is severe. This aspect of general practice
was not explored at any length at the Inquest but NHS England believe it is
important for to give great consideration to his future ability to weigh
evidence especially when a similar case presents to him in the future. For this
reason, NHS England expects [EEE to read and research the body of
academic articles that pertains to the diagnosis of venous thromboembolism
and to summarise what will change his practice.
3. Proposed Action Plan
3.1
This case starkly illustrates how difficult the diagnosis of a DVT can be for
General Practitioners bu {J needs to demonstrate that he has
carefully considered all the factors that present in this case and to write
reflectively:
7 At the time of post mortem the difference in leg circumference between the left and the right leg was less than 3.cm difference, measured at 10cm below the tibial
tuberosity. If he had elicited and recorded this sign, it would not have supported the diagnosis of a DVT.
Page 7 of 9
e onthe research he has undertaken relating to the clinical diagnosis of DVT
and the challenges it presents to the practitioner.
e on the significance of a family history of thromboembolic disease and the
current hypothesis of a genetic association.
e about the medical history he actively seeks when presented with a patient
complaining of a painful calf
e about the medical examination he will undertake in the future. What does he
think is an appropriate method to examine the patient?
e how this case has changed his management of future patients with similar
presentations and in particular how he would safety net (and record it ) more
effectively in future.
This reflective report should be submitted to NHS England by 14° May 2014.
3.2 eS cus to improve his record keeping. It is expected that he will
attend a course on medical record keeping by no later than 30 June 2014.
After the course he is to write a reflective account of what he has learnt and
how it will change his practice and share this with NHS England. To be
completed by 28" July 2014.
3.3 After EEE attends the course on medical record keeping he is to
undertake an audit of his medical record keeping. This will follow the method
employed by the IMAP process. See Appendix. To be completed by 28" July
2014.
NHS England plan to meet up with again in the next month so this action
plan can be discussed in detail and the exact timetable agreed.
Yours sincerely
Associate Medical Director (South London Area Team)
MBBCh, FRCGP, LLM, PGCE, DRCOG, DGM
Page 8 of 9
Appendix 1:
Taken from :
Interim Membership by Assessment
of Performance (iMAP2)
April 2013
https://www.rcgp.org.uk/GP-training-and-exams/~/media/Files/GP-training-and-
exams/iMAP/iMAP2%20Handbook%20Jul%2013.ashx
This proforma will be used as the basis of a self — reported and self — analysed medical
records review. a wi! be expected to reflect on the outcome after the exercise
has been completed.
| be asked to look at 30 consecutive records.
13. Good medical records
EVIDENCE/PROFORMA
10 copies of single note entries. Tick if information is present in your records.
Page 9 of 9
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