Prevention of Future Deaths reports · 2013
Regulation 28 report to prevent future deaths, reference 2013-0321, written 4 Dec 2013. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 4 Dec 2013 |
|---|---|
| Reference | 2013-0321 |
| Deceased | Yuki Ivy Norman-Knight |
| Coroner | David Osborne |
| Coroner area | Norfolk |
| Category | Community health care and 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.
INQUEST TOUCHING THE DEATH OF YUKI NORMAN-KNIGHT
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS
"NOTE: This formn is to be used after an inquest.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT 1S BEING SENT TO:
The Practice Manager
St Stephens Gate Medical Practice
55 Wessex Street ;
Norwich
NR2 2TJ
1 | CORONER
lam DAVID OSBORNE, Assistant Coroner, for the Coroner area of
| NORFOLK
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.
3 | INVESTIGATION and INQUEST
_On 14 MAY 2012 | commenced an investigation into the death of YUKI
IVY NORMAN-KNIGHT AGED 9 MONTHS. The investigation concluded
at the end of the inquest on 26 NOVEMBER 2013. The conclusion of the
inquest was that Yuki died from natural causes the medical cause of
death being Haemophilus Influenzae Bronchopneumonia.
4 | CIRCUMSTANCES OF THE DEATH
At the time of her death on 21 April 2012 Yuki had been suffering from a
-| persistent cough. She was seen on three occasions in November and _.
‘December 2011 and January 2012 at the Timber Hill walk in centre.
She was then seen twice at St Stephens Gate Medical Practice, the GP
Practice where she was registered following her birth, by practice nurses
-on 14 and 26 March 2012. On each occasion a diagnosis of chest
| infection was made and she was prescribed a 7 day course of antibiotics.
She had improved for one day following the first course but then relapsed
leading to her second attendance at the GP surgery. She was not seen
on either occasion by a doctor, although on the second occasion the
on
practice nurse gave details to a doctor when seeking his signature on the
script. ;
Sadly and tragically Yuki died on 21 April 2013 having become
unresponsive whilst with her father; who commenced CPR and called '
999, and taken by ambulance to Norfolk and Norwich University Hospital
where despite continuing efforts she was declared deceased. .
CORONER’S CONCERNS .
During the course of the inquest the evidence revealed matters giving rise
to concern. In my opinion there is a risk that future deaths will occur
unless action is taken. In the circumstances it is my statutory duty to
report. to you.
The MATTERS OF CONCERN are as follows. —
(1) Evidence given at Inquest from the Timber Hill walk in centre was
that'a record of a patient's attendance, if not registered at that
practice, would be sent either electronically or by fax to the.surgery
where the patient was registered. In their-evidence to the Inquest
the practice nurses who saw Yuki at St Stephens Gate Medical
_ Practice could not recall if they had access to this information. |
am therefore concerned that the systems for practice nurses
checking an attending patient’s past medical history, especially
where the patient is a very young child or baby may need review.
(2) On the evidence given to the Inquest there appeared to be no
guidelines or triggers for when a practice nurse should refer-a
patient fo be seen by a doctor. | am therefore concerned that the
systems at St Stephens Gate Medical Practice for such a referral,
especially in the case of a very young child « or baby may need to
be reviewed.
(3) The evidence given to the Inquest was that when a caller
telephoned the St Stephens Gate Medical Practice for an
appointment the receptionist would ask the caller if they were
happy with a nurse practitioner appointment. If the caller said they
wanted a doctor then a doctor's appointment would be given.
There appeared to be no guidelines for the receptionist or trigger
for a doctor's appointment to be made in the absence of any
specific request by the caller. | am therefore concerned that the
systems for making appointments at the St Stephens Gate Medical
Practice may need reviewing in particular whether there should be
guidelines and/or triggers for a doctor's appointment as opposed to
nurse practitioner when the appointment is for a very young child
or baby.
‘
6 | ACTION SHOULD BE TAKEN
In my opinion, action should be taken to prevent future deaths and |
believe you and/or your organisation have the power to-take such action.
7 | YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date
of this report, namely by 4 Februaty 2014. |, the Assistant 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:
mother)
EE (2:7 |
HE Ganctatner)
Norfolk Safeguarding Children Board
Room 60
Lower Ground Floor ;
County Hall Martineau Lane
Norwich
NRi 2UG
Derek Winter (Archivist)
HM Coroner for the City of Sunderland
Civic Centre ©
Burdon Road
Sunderland
SR2 7DN
| 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.
9 {4 December 2013 SrA
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.
55 Wessex Street Norwich NR2 2T) — Secretaries: St Stephens Gate iV FP PRAC TECS www.ststephensgate.com Mr David Osborne ANP (n) fall iy i _ Assistant Coroner Norfolk District | ALL Li Norfolk Coroner's Service 69-75 Thorpe Road i, de. ~3r Norwich fie Fro 2m, Norfolk acres, ht vf NR1 1UA a . Dear Sir, INQUEST IN TO THE DEATH OF YUKI NORMAN-KNIGHT — RESPONSE TO MATTERS OF CONCERN 1. Ifa patient attended another organisation that is using the SystmOne clinical software then the following is noted on their record (example): ‘Care started at Timber Hill Health Centre (Walk In Patient)’. This entry would automatically show the date, time and the consultation, as well as who the patient was seen by. The entry would include advice given and any medication prescribed. After the consultation the system would show: ‘Care ended at Timber Hill Health Centre (Walk In Patient)’. This entry would also show date and time. However: we would not be able to see the detail of the consultation if SystmOne showed: ‘Patient dissented to their record at another organisation being shared.’ or ‘Event has been made private by another organisation.’ In other words, our ability to see the consultation details at another venue is reliant on the patient's consent. However, in the instance where consent has been given, we confirm that the information can be seen and that all nursing staff check records accordingly. Whilst this would be standard procedure in any case, we have reviewed and reinforced the need for all clinicians to check patient past clinical history at each appointment. If a patient is seen in A&E or by the OOH team, then the report is electronically linked to a patient and shown under communications on the patient record. However, in the case of A&E attendances the Practice may not receive notification for some days; but we would assure you that as soon as notification is received in Practice it is immediately scanned into the Patient’s notes. In the case of a young child the parent or guardian would be in a position to inform the clinician that the child had been seen at or by the above. 2. St Stephens Gate Medical Practice assures the Coroner that any Nurse Practitioner or Practice Nurse will have the support of a duty doctor at all times. Moreover, the Practice is arranging for a paediatrician to attend here and present a module on ‘Referral for a Sick Child’, and also for all Clinicians to undertake: ‘Spotting The Sick Child’, an e-learning tool commissioned by the Department of Health. . NICE Guidance states: ‘fever in young children can be a diagnostic challenge for healthcare professionals because it is often difficult to identify the cause. In most cases, the illness is due to a self-limiting viral infection. However, fever may also be the presenting feature of serious bacterial infections such as meningitis or pneumonia. A significant number of children have no obvious cause of fever despite careful assessment. These children with fever without apparent source are of particular concern to healthcare professionals because it is especially difficult to distinguish between simple viral illnesses and life-threatening bacterial infections in this group.’ In recognition of this NICE guidance, in the event of any doubt a nurse would refer to or at the very least discuss a case of concern with a GP. We use the NICE ‘Traffic Light System for Identifying Risk of Serious Iliness [new 2013]’, and are arranging for laminated copies of the Traffic Light guidance to be present on desks in all nurses’ consulting rooms. 3. Medical practice receptionists are not qualified to triage clinically. When the parent or guardian of a sick child calls for an appointment, the receptionist will ask whether an appointment with a Nurse Practitioner or Practice Nurse is suitable. If the parent/guardian indicates that there is concern that this might not be suitable, or a Nurse appointment is declined by the parent/guardian, then the child would either be booked a GP appointment or the Duty Doctor asked to triage. We also have guidance for immediate Duty Doctor response; for example if the parent/guardian states that the child has difficulty breathing, or a non-blanching rash. The outcome here might be that the patient would be advised to attend the Surgery as a matter of urgency or an ambulance called on their behalf. Two points we wish to reinforce here are that the entire Practice team works extremely hard to ensure that we avoid any delay in a patient being seen, and that a sick child would always be offered an appointment with a practitioner capable of dealing with the problem. We have also undertaken a survey of contacts by parents/guardians of patients under one year that we have had, over a period of one month. We will then discuss the issue at a clinicians’ meeting to establish whether all under-one year olds should be triaged by a GP. Finally, we would wish to reassure you that we have discussed the outcomes of this case at practice clinical meetings, and have reviewed our policies and procedures accordingly. We offer our most sincere condolences to the family of Yuki and, of course, wish to play our part to ensure that any risks of such a tragic instance occurring again in the future are eliminated as far as possible. Yours sincerely, Practice Business Manager —
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