Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0251, written 4 Jun 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 4 Jun 2014 |
|---|---|
| Reference | 2014-0251 |
| Deceased | John Day |
| Coroner | Caroline Sumeray |
| Coroner area | Isle of Wight |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (2) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Dr John Rivers, Executive Chair and Clinical Director, The Isle of Wight Clinical Commissioning Group, Building A, The Apex, St Cross Business Park, Newport, Isle of Wight. PO30 5XW 2. Medical Director, Beacon Healthcare, St Mary’s Hospital, Parkhurst Road, Newport, Isle of Wight, PO30 5TG 1 CORONER I am Caroline Sarah Sumeray, Senior Coroner for the Coroner Area of the Isle of Wight. 2 CORONER’S LEGAL POWERS I 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 On 7th April 2014 I commenced an investigation into the death of John William Day, aged 76. The investigation has now concluded and no inquest has been held. The medical cause of death was found to be: 1a Acute Exacerbation of Chronic Obstructive Pulmonary Disease 1b 1c II Cardiac Failure 4 CIRCUMSTANCES OF THE DEATH 1) John Day lived alone in a small flat which appeared to be within an assisted living environment with no care on site. He had respiratory issues and was on oxygen for much for the time. He suffered with COPD and heart failure. 2) During the evening of 5th April, Mr Day called a friend to say that he was having problems breathing. The friend called an ambulance for him as she was at work and unable to attend. 3) The ambulance crew arrived and advised that Mr Day should attend hospital. He refused as he has a Do Not Attempt Cardio Pulmonary Respiration (DNACPR) in place. The ambulance crew called for an on-call doctor from the Beacon to attend. Dr Oommen John attended and questioned Mr Day regarding any allergies, of which Mr Day said he had none, before prescribing him Prednisolone and Co-Amoxiclav. 1 4) did not have access to Mr Day’s medical records. Had he been able to access them, he would have seen that Mr Day was, in fact, allergic to Co- Amoxiclav. 5) Mr Day was found dead in his chair whilst still attached to his oxygen supply, by his friend on 6th April 2014. 6) Mr Day’s post-mortem showed that he had died of natural causes and that the Co-Amoxiclav had not caused an allergic reaction despite his known allergy to this drug. 5 CORONER’S CONCERNS During the course of the investigation my inquiries 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) During the course of my investigation, I heard live evidence from who was the out-of-hours doctor who visited Mr Day. He told me that he medical records and that this was a common did not have access to situation. He said that he had asked Mr Day if he had any allergies to medication, and Mr Day replied that he did not have any such allergies. Whilst Mr Day appeared to have capacity, the information which he gave to was incorrect, and as a consequence, Day. prescribed Co-Amoxiclav to Mr (2) In this case, the patient did not die as a result of the medication which was prescribed, but if the patient had died, an inquest would have inevitably resulted. Moreover, the patient had capacity to give an (incorrect) answer, but if the patient lacked capacity to do so, I am concerned that the out-of-hours doctor has no way of verifying the appropriateness of the medication which he wishes to prescribe. Accordingly I am concerned that there is not a way in which out-of- hours doctors can access the “Allergies” section of a patient’s medical notes in every case. As I understand it, even if a patient opts out of the NHS Spine, the information about allergies should still be available to any medical personnel who consult the database. 6 ACTION SHOULD BE TAKEN In my opinion urgent action should be taken to prevent future deaths and I believe you and 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 Wednesday the 30th of July 2014. I, 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. 2 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: and . I 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 H.M. Senior Coroner – Isle of Wight 4th June 2014 3
2 responses 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.
RECEIV 31 JuL 20 Th Beach Health}? St Marys Centre Hospital Response to matters of concern raised in the Regulation 28: Report to Prevent Future Deaths (2) in relation to the death of Mr John Day The concerns raised in section 5 are about access to a patient’s records out of hours and, although it did not apply in this case, the potential risk to a patient who lacks capacity, if this is not available. It is unfortunately the case that there is no system currently available to GP out-of hours services that has the capacity and capability to provide a clinician with all the patients GP clinical records although previous contacts with the out of hours service are accessible, locally, via the dedicated out of hours system, Adastra. Whilst all UK residents, unless they opt out, can be checked against the National (NHS) spine, this only gives the demographics of that patient and not any clinical record, so this would not provide information about allergies. Whilst it is planned that there will be access to the Summary Care Record through the National Spine this does not function fully yet and we have not succeeded when attempted by the Beacon services. We are fortunate in that all the GPs on the island have the same primary care computer system which should allow some limited sharing of clinical information locally, through a system called Vision 360 but this has largely failed to function, is cumbersome and could not be accessed by the mobile GP because the limited ability to transfer data to the laptops in the cars due to the band width. In the case of a patient who lacks capacity, it would be possible, although time consuming, for a GP in the community to contact a GP colleague at the base to see if Vision 360 is functioning and then to check for allergies or other serious and appropriately important conditions that might have any impact on the treatment being considered. This, even then, does rely on the information being correct and complete on the GP system and would not be possible to access in the case of non island residents. In this case the patient was deemed to have capacity firstly by the paramedic, as they accepted his refusal to go to hospital, and then b Mr Day denied any allergies to both of these clinicians so there was no reason to check the veracity of the patient’s response even if access to Vision 360 were more reliable. All the GPs working in the out of hours service are aware of the potential, but unreliable, access to Vision 360 and, as a matter of normal good clinical practice, would attempt to access it if they significant concerns about initiating a treatment with a potential serious allergic response ina patient without capacity. A SMOKEFREE Isle of Wight The Beacnt Health | St Mary's Centre Hospital There is no integrated health care record system in the UK that we could adopt that would deliver a comprehensive and mobile health care record across all systems but we are leading the way on the development of that integration on the island. The Beacon out of hours service is working closely primary care, the ambulance service and secondary care. We have already integrated the Adastra system into the overarching hospital system ISIS. Better links between this and the primary care system (Vision) are limited by the unreliability of Vision 360 which is a problem nationally and not within our control. it is more likely to be resolved by a change it the islands primary care system. Actions taken 1. Reminder sent to all out of hours GPs to consider trying to get access to Vision 360 if clinically indicated. 2. To continue to press for improvements in the IT systems to be able to deliver mobile access to patients clinical record. Beacon Medical Director VA SMOKEFREE Isle of Wight
NHS:
Isle of Wight Clinical Commissioning Group
22
Building A
The APEX
St. Cross Business Park
Newport
Isle of Wight
PO30 5XW
25 July 2014
Ms C Sumeray
HM Senior Coroner, Isle of Wight
Coroner’s Office
3-9 Quay Street
Newport
Isle of Wight
PO30 5BB
Dear Ms Sumeray
Re: Regulation 28: Report to Prevent Future Deaths (2)
Investigation in to the death of Mr John William Day
Thank you for your correspondence dated 4 June 2014 in which you raised concerns about
access to medical records for GPs working out of hours. | understand that you will also be
receiving a reply fror{EEEEEEE Who is the medical director for the GP out of hours
service. His reply deals in some detail to explain the limitations of accessing information from
patient records.
As chair of the organisation responsible for commissioning out of hours GP services and as a
practicing GP | am familiar with the severe limitations of the current information systems
available to out of hours doctors. There have been various attempts to improve clinical
information sharing through IT developments, nationally, regionally and locally. Results have
been variable and often of limited functionality. In particular difficulties relating to consent and
information governance have resulted in incomplete access. The technical problems mean
that even the system on the Island [Vision 360] is not easy to access and not always reliable.
As such when consulting with a patient who is deemed to have adequate capacity it would be
normal practice to ask that patient whether they were aware of any allergies and act solely on
that information. Current working practices and systems would not allow routine checking with
the patient record.
Commissioning high quality,
sustainable and integrated services
The Island CCG, along with all other CCGs, is developing a system-wide IT strategy. The aim
is to move towards a universal, integrated and readily accessible health care record. This
would have considerable benefits to delivery of care in a range of ways of which out of hours
access is only one. Frustratingly the practical problems to progress this are considerable and
wide ranging. , explains — the Island is making significant advances
with the introduction of an overarching system [ISIS] but we have a long way to go before
there is a fully operational shared information system.
Yours sincerely
Chair & Clinical Lead
Isle of Wight Clinical Commissioning Group
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