Prevention of Future Deaths reports · 2014
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 report | 12 Feb 2014 |
|---|---|
| Reference | 2014-0061 |
| Deceased | Refat Hussain |
| Coroner | Dr Fiona Wilcox |
| Coroner area | London Inner (West) |
| Category | Hospital Death (Clinical Procedures and medical management) 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 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. =
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.
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
See every Prevention of Future Deaths report matching Hospital Death (Clinical Procedures and medical management) related deaths, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.