Prevention of Future Deaths reports · 2014

Refat Hussain

Regulation 28 report to prevent future deaths, reference 2014-0061, written 12 Feb 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report12 Feb 2014
Reference2014-0061
DeceasedRefat Hussain
CoronerDr Fiona Wilcox
Coroner areaLondon Inner (West)
CategoryHospital Death (Clinical Procedures and medical management) related deaths
Sourcejudiciary.uk record · original PDF
Responses published1

The report

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

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
1. The Clinical Director,
Harmoni HS,
1° Floor,
125, Upper Richmond Road,
Putney,
London.
SW 15 2TL
4 CORONER
| am Dr Fiona Wilcox senior coroner for the coroner area of Inner West London.
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 12" June 2013 | commenced an investigation into the death of Refat Hussain aged
25 years. The investigation concluded at the end of the inquest on 17° December 2013.
The conclusion of the inquest was Medical Cause of death:
1a Multi-organ failure.
b In hospital cardiac arrest
c Pulmonary Tuberculosis and pneumonia
Il Rubenstein Taybi Syndrome.
Conclusion of the Coroner as to the Death:
On 15/4/2013 Ms Refat Hussain was admitted to St Georges Hospital. She was
initially diagnosed with bilateral community acquired pneumonia, was treated and
improved a little. However, she developed haemoptysis on 21/4/2013 and suffered
a cardiac arrest on 22/4/2013. She was confirmed the same day as suffering form
pulmonary TB. Despite all active treatment she deteriorated and died on ITU on
11/5/2013. She had developed active signs of TB in February 2013. If she had been
diagnosed and treated appropriately at that time then on the balance of
Probabilities the death would have been averted.
4 | CIRCUMSTANCES OF THE DEATH
Ms Hussain was part of an extended family most of whom developed either open TB or
latent TB at the material time. Refat herself had been diagnosed with latent TB but had

1

not received treatment for this. In the early of February 2013, she had developed
symptoms consistent with active TB, which for various reasons went unrecognised.

On 30” March 2013, she was visited at home by a Harmon who
based upon the history given at the time and the examination of Ms Hussain, diagnosed
a chest infection and prescribed antibiotics.

| ee no access to Ms Hussain’s usual GP records, nor that of her family
members which may have assisted him to make the diagnosis of TB and arrange
appropriate treatment. It is possible that had had such background information
this death may have been averted.

Based upon the information available to him] diagnosis and treatment was
reasonable and appropriate. This situation was further complicated as Ms Hussain was
unable to give a clear history herself due to her Rubenstein Taybi syndrome.

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) The lack of access to the patients GP medical records reduces the ability of out of
hours GPs working for Harmoni to make accurate diagnoses.

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.

YOUR RESPONSE

You are under a duty to respond to this report within 56 days of the date of this report,
namely by 12" April 2014. |, 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
ce

2

The Heritage Medical Practice,
119 Northcote Road,
Battersea,

London. SW11 6PW.

3,

Consultant Medical Microbiologist,
St Georges Hospital,

Blackshaw Road,

London. SW17

| have also sent it to : The Care Quality Commission 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.

9 | 12” February 2014

CTs

Dr Fiona Wilcox,

HM Senior Coroner Inner West London,
The Coroner’s Court,

65 Horseferry Road,

London.

SW1P 2ED.
=

Responses

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.

Response from Care UK (PDF)
care  

Care UK Clinical Services 
Limited 
Hawker House 
5-6 Napier Court 
Napier Road 
Reading 
Berkshire 
RG1 8BW 

20th  March 2014 

PRIVATE AND CONFIDENTIAL 
Dr Fiona Wilcox 
HM Senior Coroner Inner West London 
The Coroner's Court 
65 Horseferry Road 
London 
SW1P 2ED 

Dear Dr Wilcox 

INQUEST TOUCHING ON THE DEATH OF MS. REFAT HUSSEIN ("MS HUSSEIN") AND 
YOUR REGULATION 28: REPORT TO PREVENT FUTURE DEATHS DATED 12 
FEBRUARY 2014 (THE "REPORT") 

I am writing this letter in response to the Report. I am the Medical Director for Urgent Care 
within Care UK which, since November 2012 Harmoni has been wholly owned by Care UK. 

We fully appreciate that in providing high quality Out of Hours ("OOH") medical care it is 
highly desirable to have access to information from the patient's registered General 
Practitioner ("GP"). During his review of GP OOH services in 2000, 
emphasised this very point and at the time of his review, he was confident that a  national 
programme to deliver electronic records would address this. Regrettably, this project did not 
deliver. 

As you may appreciate, there are a number of GP IT systems that necessarily underpin 
consultations and the organisation of In Hours care in General Practice. Whilst there is 
increasing interoperability between these systems, we are not yet at the stage where records 
are easily shareable between GP practices and OOH providers. 

Our OOH information system, called Adastra, does communicate with daytime GP practices 
in the sense that, after an OOH consultation has taken place the GP practice receives a 
"post event message" ("PEM") detailing the consultation that has taken place in OOH period. 
The PEM contains a  summary of the consultation notes. As such, our OOH service is able to 
communicate with GP practices. However, the reverse (i.e. an information flow from a GP 
practice to OOH as a matter of routine) is simply not possible under current NHS protocols. 
Our clinicians are not routinely able to see records from daytime GP computer systems. This 
situation applies generally to OOH services and is not specific to Harmoni/Care UK. 

At its most basic level, this means our OOH clinicians have to ensure that they take a careful 
history from patients and their carers and/or family to ensure that they can deliver a high 
quality medical assessment and appropriate treatment. To us, this is not satisfactory and we 
are aiming to exert what influence we can to change the current state of affairs for the 
benefit of patients 

As such, we have not been complacent about this concern and have taken, and continue to 
press GPs to submit information to us about patients who have long term conditions, are 
very poorly or vulnerable. This is achieved through a  system called Special Patient Notes 

Care UK Clinical Services Limited 
Registered Office :, Connaught House,  850 The Crescent, Colchester Business Park, Colchester, Essex,  CO4 9QB 
Registered company number: 03462881 

 
 
 
 ("SPN"). GPs can submit SPNs in either written form that we can transcribe into our records 
or preferably, can use a web portal to submit the SPN directly into our systems. We provide 
templates of the most common forms of SPN to try to ensure that the correct data is 
captured and the system we have implemented reminds GPs when SPNs that have been 
placed on the system by that GP are due for review. 

In addition to this, we are working closely with the Health and Social Care Information 
Service ("HSCIS") to ensure that systems are in place to ensure that we can see patients' 
Summary Care Records ("SCRs"). The SCR is a direct element of GP patient records and 
has the potential to be enormously helpful in ensuring that we have access to important 
information extracted from the patient's registered GP. Together with HSCIS, we are 
promoting this nationally as SCRs will only become truly useful when more GPs have 
uploaded them and the content of the SCR is expanded. 

I should also add that in London, we also work closely with NHS England to ensure that our 
OOH (and other) services can access patient records on a system called Coordinate My 
Care ("CMC"). CMC is widely used across London to try and integrate the daytime medical 
care, community nursing care, hospital care and OOH care. 

An important factor applying to all of the above developments is that the onus is on the 
registered GP practice to enable us to access information. 

I hope that this letter illustrates that this is an issue that we take extremely seriously and are 
working diligently to resolve. I am happy to provide any further information or clarification 
that you may require. 

Yours sincerely 

Medical Director —  Urgent Care 

Page 2 of 2

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