Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0345, written 25 Jul 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 25 Jul 2014 |
|---|---|
| Reference | 2014-0345 |
| Deceased | Clare Cooper |
| Coroner | Karen Henderson |
| Coroner area | Surrey |
| Category | Community health care and emergency services related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 4 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
1.
2.
3.
4.
5.
6.
– Woodlands Surgery
– East Surrey Clinical Commissioning Group
Associate Director – Eating Disorder Services for Adults
President – Royal College of Physicians
President – Royal College of Pathologists
Chair – Royal College of Psychiatry, Eating Disorders
1
CORONER
I am Karen HENDERSON, assistant coroner for the coroner area of Surrey
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 and INQUEST
On 11th July 2014 I commenced an investigation into the death of Clare Serena Anke COOPER, 24 years
of age. The investigation concluded at the end of the inquest on 11th July 2014. The medical cause of
death given was:
1a. Addisonian Crisis
1b. Undiagnosed Addison’s disease
2. -
My narrative conclusion was:
Clare died from the consequences of Addison's disease when opportunities were lost with
diagnosis and treatment which could have affected the outcome
CIRCUMSTANCES OF THE DEATH
4
Ms Cooper was a previously fit and well young adult who had rarely troubled her GP throughout her short
life. She presented to her GP in May 2012 complaining of weight loss and excessive tiredness.
Reassurance was given but little evidence was documented to confirm the symptoms were explored in
depth by taking a history or undertaking simple measurements such as weight and other vital signs (HR,
BP etc.) at the time or subsequently. However a blood test was ordered by the GP to assess Ms Cooper’s
immune status, which was found to be normal.
Ms Cooper presented again to her GP surgery in September 2012 after a significant ‘faint’ but nothing
relating to this was recorded in the notes (only treatment for a long-standing foot disorder). Ms Cooper
further presented to the GP practice in October, November and December 2012 with a continuing and
increasing history of lassitude, difficulty in eating resulting in further unwanted weight loss and increasing
anxiety. Latterly she chose to see a different GP as she felt her symptoms were not being taken seriously
by her own longstanding GP. Documentation of the latter consultations were scant and do not confirm
there was an in depth history taken to assess the severity and nature of the presenting and persistent
symptoms. Whilst a body weight was measured at least once in December there was no indication of any
other measurement of her weight and it was therefore not possible to quantify the proportion of weight
lost. Vital signs (heart rate, blood pressure etc) were also not measured and I heard evidence that it may
have shown significant evidence of a postural drop, which may have prompted further investigation.
Ms Cooper had a blood test organised by the GP’s in November and a further three in December 2012.
Whilst she had a normal blood sodium in November 2012 (136 mmol/l) two sequential tests in quick
succession in December showed an isolated low blood sodium of 126 mmol/l. A further blood test two
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
weeks later indicated the sodium had returned to normal levels at 136 mmol/l. No significance was
attached to the low sodium levels other than a presumption it may have arisen from a reduced diet or
from vomiting which was mild (2-3 times a week). I heard expert evidence that Intermittent vomiting and
food restriction would not ordinarily cause a low sodium, particularly when all other electrolytes were
normal. I also heard evidence that an isolated blood sodium of 126 mmol/l should have been
independently investigated in its own right, particularly if there is an absence of common causes (usually
in the elderly) such as prescribed medication and despite the fact it had ostensibly returned to normal.
I heard evidence that there was no formal protocol in place at the GP surgery to ‘flag-up’ abnormal results
and no system in place to assess and manage electrolyte abnormalities. Equally there was no formal
system in place for a clinical pathology service to highlight abnormal results to the relevant GP practice.
In any event no other investigations were undertaken at the GP surgery to explore the possible cause of
the low sodium and simple measures such as the measurement of vital signs and regular weight
measurements in the presence of weight loss were not undertaken. Also, no consideration was give to a
referral to hospital to assess whether there was a physical/organic cause of her symptoms and/or
hyponatraemia. As it was, the final ‘normal’ sodium was likely to have been falsely reassuring.
I also heard evidence that there is a lack of clarity locally and nationally as to how low a blood sodium
level should be (either consistently or intermittently) before requiring assessment and investigation
(although it was agreed a level of 126 mmol/l fulfilled the criteria). Also, ‘clinical practice’ medical
textbooks were also unhelpful with regard to the management of low blood sodium levels with little
emphasis on looking for a clinic-pathological connection. Thus a young person with an intermittently low
sodium level may require a higher index of suspicion rather than individuals with underlying medical
conditions or on prescribed medication known to cause a low sodium level.
At the same time, Ms Cooper’s lassitude was such she was signed off sick from work in November 2012
and she did not work again. Again the significance of this was not explored. She was then referred to the
Eating Disorder Service (EDS) in December 2012 although there was no evidence she was deliberately
attempting to lose weight or worried about putting on weight. Ms Cooper was seen for triage at the EDS
In January 2013 and she was found not to satisfy the criteria for an eating disorder. It was thought her
poor appetite was a consequence of her anxiety although a cause of her anxiety was not examined in
detail. A physical cause was not considered for her symptoms other than a thyroid function test even
though Addison’s disease is a rare but well recognised cause of weight loss and difficulty eating. She was
discussed at a multidisciplinary meeting and it was decided to continue to care for Ms Cooper to develop
strategies associated with her anxiety as a cause of her poor appetite. She was also prescribed Fortisip
and on follow up her weight had increased by approximately 1kg confirming, in part, she had no fear of
gaining weight.
I heard evidence the proforma used for triage at the EDS was overly focussed on psychological causes
rather than a possible underlying physical cause of the signs and symptoms of an eating disorder and it
was without adequate prompts to obtain relevant information which may have prompted an investigation
for a physical cause of her symptoms. This includes no clear policy for screening for organic/physical
illness or to have the full set of notes from the GP/clinical practice available at initial assessment. I also
understand that this may be an issue nationally on a survey undertaken by the family of Ms Cooper with
regard to EDS proformas from various institutions. Also, the risk assessment form for all mental health
services was not thought to be sufficiently reflective of the needs of the eating disorder clinic.
Retrospectively her parents commented that she had developed a love of salty food (eating noodles at
breakfast covered in soy sauce) and had began to tan easily for 12-18 months prior to death but the
significance was not understood at the time and were therefore not highlighted to the medical doctors
caring for her. Unfortunately Ms Cooper continued to deteriorate at home with increasing severe
symptoms of lassitude, dizziness, nausea and difficulty eating. She sadly had a cardiorespiratory arrest at
home on 1st February and despite aggressive resuscitation after emergency admission to East Surrey
Hospital she died on 2nd February 2013 (not sure of the dates).
I heard expert evidence that the constellation of signs and symptoms were such that it was highly likely
Ms Cooper was suffering from Addison’s disease, which was not recognised as such. I concluded her
final admission into hospital and subsequent death was from an Addisonian crisis and that whilst it is a
very rare disease, her underlying symptoms and signs in the presence of a low blood sodium level were
such that they required independent investigation whether or not Addison’s disease was a consideration.
1
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
I also heard evidence that the diagnosis of Addison’s disease is difficult to diagnose at post mortem as
changes to the adrenal gland may be subtle and as such there should be a higher index of suspicion in
unexplained deaths in the young population to look for Addison’s disease rather than giving a cause of
death as Sudden Adult Cardiac Death syndrome (which was the initial cause of death given at PM). I also
received evidence that pathologists undertaking coronial post mortems can be supplied with all the
hospital or GP notes rather than relying on the coroner’s death report with the possibility of improving
clinico-pathological correlation in cases where death is uncertain or unascertained.
5
CORONER’S CONCERNS
During the course of the inquest the evidence revealed matters giving rise for concern. In my opinion
there is a risk that future death 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. Poor GP documentation
2. Lack of evidence of a robust assessment of presenting signs and symptoms with a presumption
of a psychological/psychiatric problem without considering or excluding an organic cause.
3. Lack of GP routine vital sign monitoring e.g. heart rate, blood pressure and weight measurement
when weight loss is a concern with a lost opportunity to assess the severity of weight loss.
4. No established system for recognition, assessment and management of electrolyte abnormalities
within the GP practice and/or consideration of the chemical pathology service to ‘flag-up’
particularly concerning results.
5. Lack of understanding of the underlying causes of hyponatraemia (consistently or intermittently
low) and the level below which will require further investigation, and the investigations that should
be carried out, particularly in circumstances when there is no obvious cause of the low sodium.
6.
7.
Insufficiently detailed referral letter to EDS (mentioning ‘low sodium’ but not accompanied with a
copy of the blood results) and an opportunity was lost for its significance to be considered
Insufficiently robust EDS proforma used to triage patients for an eating disorder: lack of prompts
and a need to emphasise and exclude possible organic causes, however rare. The lack of a
documented list of potential diagnoses to be assessed and excluded at triage, including organic
causes. A need to facilitate communication from the referral agents to the eating disorder service.
8. The lack of a national protocol for assessing patients seriously ill with an eating disorder with the
possibility of detecting individuals with an organic basis for the condition.
9. Lack of hospital or GP notes available for the pathologist undertaking the post mortem to facilitate
a greater opportunity for clinic-pathological correlation in deaths which are unascertained and a
higher level of suspicion to explore rare causes of unexpected death, especially in the young.
10. The need to highlight this case nationally to clarify published guidance with regard to the causes,
investigation and treatment of low blood sodium and to reinforce the importance of excluding an
organic basis of an illness before labelling the condition a psychiatric or psychological disorder.
6
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe the GP practice (Woodlands
Surgery) and other organisations; East Surrey Clinical Commissioning Group, Eating Disorder Services
for Adults - Surrey and Borders NHS Trust, Royal Colleges of Physicians, Pathologists and Psychiatry,
Eating Disorders, have the power to take such action.
2
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
7
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report. I, the coroner, may
extend this 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
I have sent a copy of my report to the Chief Coroner and to the following Interested Persons;
- Chief Medical Officer – Department of Health
– NHS Medical Director, NHS England
– Medical Director, Health Education England
– President, Royal College of General Practitioners
– President, Royal College of Psychiatrists
Chair, Joint Commissioning Panel for Mental Health
– Chair, Joint Commissioning Panel for Mental Health
Professor of Endocrinology Oxford University, OCDEM
– Consultant Psychiatrist in Eating Disorders
– GP, Woodlands Surgery
– Expert General Practitioner
– Consultant Endocrinologist, Brighton & Sussex University Hospitals
Medical Defence Union
Medical Protection Society
Medical Defence Union of Scotland
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
DATE: 25th July 2014 SIGNED: Dr Karen Henderson
3
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
4 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.
RC Royal College of GP General Practitioners Honorary Secretary Dr Karen Henderson HM Coroner for Surrey HM Coroner's Court Station Approach Woking+ Surrey GU22 7AP 27 August 2014 Dear Dr Henderson Inquest into the death of Miss Clare Serena Anke Cooper — RCGP response Thank you for your letter of 25 July addressed Oo | | which has been passed to me. As Honorary Secretary of the College Council, | am the College Officer responsible for responding to Coroners’ Regulation 28 Reports. | was very sorry to hear of the death of Miss Cooper and the series of events leading up to it. | set out below a brief description of the remit of the Royal College of General Practitioners and provide some detailed comments on the specific concerns you raise in your report. The role of the College The Royal College of General Practitioners is a registered charity under Royal Charter and is the largest membership organisation in the United Kingdom solely for GPs. Founded in 1952, it has over 50,000 members who are committed to improving patient care, developing their own skills and promoting general practice as a discipline. We are an independent professional body with enormous expertise in patient-centred generalist clinical care. Through our General Practice Foundation, established by the RCGP in 2009, we also maintain close links with other professionals working in General Practice, such as practice managers, practice nurses and physician assistants. As well as running the postgraduate Membership examination (MRCGP) which is now required for doctors to qualify as GPs, the College also provides continuing professional development (CPD) for its members, and these continuing programmes are also available to non-members of the College. However, not all GPs are members of the College, and older GPs may never have joined. The General Medical Council holds the register of all who are considered able to practise as GPs, and it is to the GMC that revalidated doctors will be notified. Similarly, it is not for us to comment on the performance of any individual GP and the information set out below is solely to show you what we provide in the context of training and advice to our Members. RCGP Education and Training Currently all doctors wishing to follow a career in general practice in the UK are required to undergo a 3 year programme of vocational training for general practice, based on the College’s GP Curriculum. Royal College of General Practitioners 30 Euston Square London NW1 2FB Tel 020 3188 7400 Fax 020 3188 7401 Email info@rcgp.org.uk Web www.rcgp.org.uk Patron: His Royal Highness the Duke of Edinburgh Registered charity number 223106 (The curriculum forms the foundation for GP training and assessment across the UK, prior to taking the College’s Membership Examination (MRCGP) and continues to be relevant to GPs throughout their career, including preparation for revalidation) http:/Awww.rcgp.org.uk/gp-training-and-exams/gp- curriculum-overview.aspx The GP Curriculum sets out College expectations of the standard of care that a general practitioner should provide and | will use references to the GP Curriculum as a basis for my response. Comments on Coroner's concerns on the general practitioner care provided to Miss Clare Cooper The underlying principle for a general practitioner’s management of any patient should be one of “holistic care”. This is set out in the section of the GP Curriculum entitled “the Consultation in Practice” where the following advice is set out: “As a GP you should: 6.4 Understand that consultations have a clinical, a psychological and a social component, with the relevance of each component varying from consultation to consultation (the ‘triaxial’ model)” I give below detailed comments on the first six matters of concern you list in this particular case,, ie those which directly relate to general practitioner care, setting aside your listed concerns 7 to 10 on which advice from hospital medicine will be more appropriate. 1. Poor GP documentation The College believes that sound recording systems and well organised record-systems are fundamental to good general practice and communications with fellow healthcare professionals outside the practice. This expectation is set out in the section of the GP Curriculum on “Being A GP”:. http://www.rcgp.org.uk/gp-training-and-exams/~/media/Files/GP-training-and-exams/Curriculum- 2012/RCGP-Curriculum-1-Being-a-GP.ashx ..."As a GP you should... 1.2.3 Develop the clinical skills you need in history-taking, physical examination and the use of ancillary tests for diagnosis” and “4.5.2 Develop your organisational skills for record-keeping, information management, teamwork, running a practice and auditing the quality of care” And again is highlighted in the section “The Consultation in General Practice” where the GP is enjoined under criterion 1.6 to “Effectively use patient records (electronic or paper) during the consultation to facilitate high-quality patient care” and in 1.10 to “keep accurate, legible and contemporaneous records” The qualities required of the GP in information gathering and recording and its importance for good patient care are further spelled out under the section “Patient Safety and the Quality of Care” of the GP Curriculum: ... “As a GP, you should... “Demonstrate an understanding of the connection between good data entry and improved patient health outcomes 1.14 Demonstrate how to use information management and technology (IM&T) to share information and co-ordinate patient care with other health professionals 1.15 Demonstrate an understanding of the need for information recorded in the practice clinical system to be fit for sharing with different health professionals in different organisations Royal College of General Practitioners 30 Euston Square London NW1 2FB Tel 020 3188 7400 Fax 020 3188 7401 Email info@rcgp.org.uk Web www.rcgp.org.uk Patron: His Royal Highness the Duke of Edinburgh Registered charity number 223106 1.16 Demonstrate how to use NHS electronic booking systems to tailor healthcare provision to the needs of the individual patient 1.17 Demonstrate the use of the practice’s computer system to improve the quality and usefulness of the medical record, e.g. through audit 1.18 Demonstrate effective use of interagency systems such as pathology links and GP-GP record transfer”... 2. “Lack of evidence of a robust assessment of presenting signs and symptoms ...” The following section of the GP Curriculum provides advice on the diagnosis of metabolic disorders http://www.rcgp.org.uk/gp-training-and-exams/~/media/Files/GP-training-and-exams/Curriculum- 2012/RCGP-Curriculum-3-17-Metabolic-Problems.ashx The Key Messages given on page 3 of this section are particularly relevant in this case: e “As a general practitioner(GP)you should have an understanding of how common endocrine or metabolic disorders such as diabetes mellitus, thyroid or reproductive disorders can present. You must also be aware of rarer and important disorders such as Addison's disease, which can be potentially life-threatening if missed e Biochemical tests can be diagnostic and often necessary for monitoring metabolic and endocrine diseases.so it is important for GPs to know which tests are useful in a primary care setting and how to interpret these tests and understand their limitations” 3. “Lack of GP routine vital sign monitoring eg heart rate, blood pressure and weight measurement...” 4. Noestablished system for recognition, assessment and management of electrolyte abnormalities within the GP Practice ...... 5. Lack of understanding of the underlying causes of hyponatraemia ...... Guidance on the use of routine tests in general practice is provided on page 6 of the Section on “Primary Care Management” “As a GP you should..... 1.6 Understand the use and main limitations of tests commonly used in primary care to investigate and monitor metabolic or endocrine disease, e.g. fasting blood glucose, HbA ‘1c, urinalysis for glucose and protein, urine albumin: creatinine ratio, ‘near patient testing'(point of care testing)for capillary glucose, lipid profile and thyroid function tests, and uric acid tests” 6. Insufficiently detailed referral letter to EDS...... Guidance on referral to secondary care is provided in the following sections. Being a GP http://www.rcgp.org.uk/gp-training-and-exams/~/media/Files/GP-training-and-exams/Curriculum- 2012/RCGP-Curriculum-1-Being-a-GP.ashx This section advises the general practitioner at all times to: “4.3 Co-ordinate care with other professionals in primary care and with other specialists” And spells this out as follows: “This means that as a GP you should: 1.3.2 Understand the importance of excellent communication with patients and staff for effective teamwork 1.4.2 Understand the processes of referral into secondary care and other care pathways Royal College of General Practitioners 30 Euston Square London NW1 2FB Tel 020 3188 7400 Fax 020 3188 7401 Email info@rcgp.org.uk Web www.rcgp.org.uk Patron: His Royal Highness the Duke of Edinburgh Registered charity number 223106 1.4.3 Manage the interface between primary and secondary care, including unscheduled care, accurate sharing of information on medicines and communication with other professionals 1.5 Make available to your patients the appropriate services within the healthcare system This means that as a GP you should: 1.5.2 Develop your organisational skills for record-keeping, information management, teamwork, running a practice and auditing the quality of care” (You will see that in this section, the need for excellent communication based on full, accurate records is again emphasised.) Guidance on the writing of referral letters is provided in the section “The General Practice Consultation in Practice” http://www. gponline.com/rcgp-curriculum/the-general-practice-consultation | hope you find these comments helpful. Yours sincerely Honorary Secretary Royal College of General Practitioners 30 Euston Square London NW1 2FB Tel 020 3188 7400 Fax 020 3188 7401 Email info@rcgp.org.uk Web www.rcgp.org.uk Patron: His Royal Highness the Duke of Edinburgh Registered charity number 223106
JFM/JB
19 September 2014
Dr Karen Henderson
HM Coroner for Surrey
HM Coroner's Court
Station Approach
Woking
Surrey
GU22 7AP
Dear Dr Henderson,
Re: Miss Clare Cooper (Regulation 28 Report - Action prevent Future Deaths).
Thank you for your letter dated 25.7.2014. | have been aware of this case since the family
approached me prior to the Coroners hearing, seeking to instruct me in an expert capacity
regarding their daughter's tragic death. At that stage, | indicated a conflict of interest, given my
leadership of the Royal College of Psychiatrists Eating Disorder Section, but | do therefore
have a longitudinal knowledge of the case.
| have already responded to the family’s own correspondence with myself, and | attach this for
your interest.
The issues raised in your report address the need for better EDS proformas in the triaging of
patients with eating disorders. On behalf of the Royal College of Psychiatrists, | agree with this
entirely.
However | would add two additional points. First, the Royal College of Psychiatrists is generally
concemed about risk assessment in psychiatry, over and above eating disorders, with undue
reliance on risk assessment proformas.
This is reflected in the Alderdice and the Kennedy reports on suicide and homicide prevention,
with services increasingly using risk assessment proformas as a type of ‘checklist’, necessary
but not sufficient in the evaluation of risk. Proformas provide a helpful aide memoire, but are
insufficient to allow the detection of relatively rare differential diagnoses. Thus, as well as
decent proformas, we require eating disorder specialists with adequate medical training.
As a Faculty, we assert the need for better standards of eating disorder specialism, and have
submitted a curriculum to the GMC for training standards to be met before a doctor is
recognised as a specialist in eating disorders.
Registered office: 21
Tel: +44 (0)20 7235
We also have concems over the heterogeneity of outpatient services across the UK. | have
established standards for inpatient services (available at:
http:/Awww.rcpsych.ac.uk/workinpsychiatry/qualityimprovement.aspx), but outpatient services
are based on local commissioning decisions. For example, we are aware of some outpatient
services with limited medical input.
The specific issue of robust EDS proformas is best tackled through the MARSIPAN Guidelines
of the Royal College of Physicians and the Royal College of Psychiatrists, which address
physical risk monitoring in eating disorders. | co-authored the original guideline, and have co-
authored a revised guideline, but the lead in this has been J whose expertise
in risk assessment in eating disorders is well recognised.
As you will see in my correspondence with the family, | will ask [MJ to consider how
best to disseminate robust EDS proformas across the UK health economy, probably best
tethered to the launch of the revised MARSIPAN Guidelines, which is forthcoming.
It would be within the remit of MARSIPAN to provide ‘a national protocol for assessing patients
seriously ill with an eating disorder with a possibility of detecting individuals with an organic
basis for the condition’. | also understand that a nae knowledge of this specific case.
{am likely to step down as Chair of the Royal College of Psychiatrists Eating Disorder Section
before the end of the year, though will attend the next Executive Committee Meeting in the
autumn. | will raise the issues within your letter at that meeting, but wished to correspond prior
to the next meeting, given the deadline for a response of 56 days. Thereafter, the administrator
of the committee NNN at The Royal College of Psychiatrists, 21 Prescot Street,
London E1 8BB.
Kind regards,
Consultant Psychiatrist
Surrey and Borders Partnership NHS Foundation Trust Trust Headquarters, 18 Mole Business Park Randalls Road, Leatherhead 18 September 2014 Surrey KT22 7AD Dr Karen Henderson Te: Assistant Coroner in Surrey Dear Dr Henderson Inquest into the death of Clare Cooper - REGULATION 28 REPORT TO PREVENT FUTURE DEATHS Further to the conclusion of the inquest into Miss Cooper's death on 11" July 2014, you wrote to Surrey and Borders Partnership NHS Foundation Trust in accordance with the Regulation 28 report to prevent future deaths, stating that during the course of the inquest the evidence revealed matters giving rise to concern. We would like to take this opportunity to offer our sincere condolences to Miss Cooper's family for their loss. The areas of concern you raised that relate to our Trust and our responses are detailed below: Lack of evidence of a robust assessment of presenting signs and symptoms with a presumption of a psychological/psychiatric problem without considering or excluding an organic cause We have revised our referral form in order to try and improve the quality of information that GPs provide when referring patients. The form asks for more detail from the GP including that they consider and exclude organic causes of weight loss prior to making a referral to the Eating Disorders Service. The form also highlights the need for the GP to provide further details of the nature of the eating problem, results of blood investigations, physical examination and past medical history so that all information is available prior to assessment by the Eating Disorders Service. It is hoped that as well as assisting the Service in prioritising the referral, identifying if a medical assessment is necessary and optimising the assessment process, the details required in the revised form will also act as a prompt for the GP to consider the possibility of organic disease in those presenting with eating difficulties. For a better life Trust Headquarters, 18 Mole Business Park, Leatherhead, Surrey KT22 7AD T_0300 55 5S 222 F_01372 217111 www~ssabp.nhs.uk Lack of understanding of the underlying causes of hyponatremia (consistently or intermittently low) and the level below which will require further investigation, and the investigations that should be carried out, particularly in circumstances when there is no obvious cause of the low sodium. We acknowledge the importance of increasing knowledge and awareness within the Eating Disorder Service about possible causes of hyponatremia and when to seek further investigations. We will be addressing this need through the Trust-wide eating disorders academic meeting during which there will be a teaching session for all clinical staff specifically about presenting symptoms and signs of Addisons disease including psychological manifestations, causes of hyponatremia and circumstances/levels below which further investigation should actioned. Insufficiently robust EDS proforma used to triage patients for an eating disorder: lack of prompts and a need to emphasize and exclude possible organic causes, however rare. The lack of a documented list of potential diagnoses to be assessed and excluded at triage, including organic causes. A need to facilitate communication from the referral agents to the eating disorder service. The triage assessment form was introduced a number of years ago as a screening assessment to establish if the patient met the criteria for having an eating disorder that our service could help with, rather than being developed as a comprehensive assessment form. This enables us to see people quickly and avoid waiting lists. If the person is found to be suitable for our service, they are then offered a fuller assessment. We have however reviewed our triage form to ensure that all information including physical investigations is recorded in one form. The changes made include: 1. Box to record bload investigation results 2. Box to record findings of physical examination 3. 3.Box to record details of physical symptoms and past medical history with prompts. The form also has an addendum reminding staff to be alert to the possibility of organic causes of illness when assessing new referrals. It provides a list of examples of possible conditions that may present with weight loss/eating problems. We are of the view that this revised form will prompt our staff to make contact with the GP where required to request organic causes to be ruled out. It is our expectation that in cases where any symptoms are atypical, that they would be discussed with the medical staff in the team and appropriate action would be taken. Lack of hospital notes available for the pathologist undertaking the post mortem to facilitate a greater opportunity for clinical pathological correlation in deaths which are_unascertained and _a_ higher level_of suspicion to explore rare causes of unexpected death, especially in the young. We are sorry that there was an issue with making notes available to the pathologist to facilitate a review to determine any clinical -pathological correlation. We work really closely with all interested parties to share clinical records including the Coroner and the pathologists. In this incident we shared records with the family (including the professional witness) and our Medical Records Team was in constant communication with them about access to records, but we are unable to find any information about any delays or issues with making these records available to the pathologist. We have shared this concern with our Medical Records Team and we will continue to support them in ensuring that all key records are made available in a timely manner to the pathologist in the future. Our Board has been made aware of your letter and we would like to offer our sincere condolences again to the Cooper family for their loss. We hope that the steps we have taken as outlined above assure you and Miss Cooper's family that we have leamt and continue to learn from Miss Cooper's death. Please do not hesitate to contact me or HE Director of Quality (DoN) if you require any further information. Yours sincerely Fiona Edwards Chief Executive cc GE — Director of Quality (DoN) Es — Viedical Director HE «Director of Children & Young People Services HE Director Risk & Safety (DDoN)
WOODLANDS SURGERY 5 WOODLANDS ROAD REDHILL RH1 6EY Tel. Fax: Dr Karen Henderson Assistant Coroner HM Coroner’s Court Station Approach Woking Surrey GU22 7AP 23 September 2014 Dear Dr Henderson, Miss Clare Serena Anke COOPER Regulation 28 Report — Action to Prevent Future Deaths Following the retirement of | am now the senior partner at Woodlands Surgery. |! was very upset to hear of the death of Miss Cooper and | would like to offer my condolences to her family. The report from Miss Cooper's inquest on the 11" July 2014 detailed in your letter of the 25" July has been circulated to all of the doctors here at Woodlands Surgery. We have discussed your findings and concerns at great length and have reflected on them both individually and together as a practice. We noted from your report that the diagnosis of an organic condition was not considered fully enough and that a psychological problem was considered all too readily without proper review of the history that Miss Cooper gave and the results of her blood tests. Normally at Woodlands Surgery we run personal lists and patients usually see their usual registered doctor. It would appear in this unfortunate case that Miss Cooper saw several doctors and we considered if this lack of continuity of care may have been an issue in why her abnormal blood tests were not followed up and investigated in a more robust way. We agree that consideration of an organic cause of her symptoms should have been given more consideration prior to and following the referral to the eating disorders clinic. All of the doctors at Woodlands Surgery have reflected on the matters of concern that you raise in your report, please find outlined below the comments from the practice and steps that we have taken in respect to each point of your report which relates to the care covered by the practice. 1. Poor GP documentation We have all agreed that all consultations should be fully documented in the patients’ notes. All patients should have a proper assessment of their history and a full examination should be done and routine vital signs should be recorded if they are clinically relevant. We have all agreed that the notes keeping in this case should have been better and may have compounded the issue relating to lack of continuity of care. In order to improve patient care and ensure that an episode like this is not repeated, doctors at the practice have agreed that as part of their ongoing personal development plan to submit anonymised consultation notes for their next appraisals. This will give a chance for each individual doctor's appraiser to assess the quality of note keeping. 2. Lack of evidence of a robust assessment of presenting signs and symptoms with a presumption of a psychological/psychiatric problem without considering or excluding an organic cause Upon reflection all of the doctors have agreed here at the practice that a functional cause was accepted far too readily by the doctors involved in Miss Cooper’s care and that an organic cause should have been considered and reconsidered upon subsequent consultations. Miss Cooper's hyponatraemia was dismissed too readily and should have been investigated further. 3. Lack of GP routine vital sign monitoring e.g. heart rate, blood pressure and weight measurement when weight loss is a concern with a lost opportunity to assess the severity of weight loss We have all agreed that all patients should have a proper assessment of their history and a full examination should be done. Routine vital signs should be recorded if they are clinically relevant. If a patient presents with weight loss then the weight loss needs to be objectively documented with serial weight measurements. 4. No established system for recognition, assessment and management of electrolyte abnormalities within the GP practice and/or consideration of the chemical pathology service to “flag up” particularly concerning results The system at the practice at the time for identifying abnormal electrolyte results was that all results are seen by the patients’ usual registered doctor. It is the responsibility of the patients’ usual registered doctor to action and file the results. In relation to this case the results were seen and filed by Miss Cooper's registered doctor. Miss Cooper was reviewed here at the practice within a week of each abnormal electrolyte result. The practice has considered what if any specific changes can be made to the way in which we handle abnormal pathology results as a result of this case. Unfortunately we do not consider that there are any specific system changes that can be implemented but | have highlighted to all clinicians the importance of monitoring and assessing electrolyte abnormalities and appropriate follow up. 5. Lack of understanding of the underlying causes of hyponatraemia (consistently or intermittently low) and the level below which will require further investigation, and the investigations that should be carried out, particularly in circumstances when there is no obvious cause of the low sodium We have all discussed at length the causes of hyponatraemia and the investigations required to make a diagnosis of Addison's disease. | am now sure now that all of the doctors here at the practice have a fuller understanding of this rare condition. In addition all of the GPs will now be completing the BMJ online learning e-module on hyponatraemia. We will add this learning need to our PDP’s and will be submitting this for our appraisals. We have also invited IJ Consultant Endocrinologist at East Surrey Hospital to give a lunchtime educational meeting here at the practice on hyponatraemia and Addison’s Disease. This is provisionally booked for Monday 13" October 2014. 6. Insufficiently detailed referral letter to EDS (mentioning “low sodium” but not accompanied with a copy of the blood results) and an opportunity was lost for its significance to be considered 99% of referrals from Woodlands Surgery go to Surrey and Sussex Healthcare Trust (SASH). The Trust is linked in to the pathology software so for the vast majority of our referrals the hospital does have access to our patients’ pathology results. However from now on all patient referrals will have copies of all investigations (not just blood tests) attached with them to the referral letter. 9, Lack of hospital or GP notes available for the pathologist undertaking the post mortem to facilitate a greater opportunity for clinic-pathological correlation in deaths which are unascertained and a higher level of suspicion to explore rare causes of unexpected death, especially in the young GP notes are always available for post mortem examinations. They do need however to be requested from us by the pathologist. Unfortunately the practice did not receive a request on this occasion. | hope that this response has reassured you that the practice has taken this case and your report very seriously. If you need any further information please do not hesitate to contact me. Yours sincerely, Dr Richard Adams
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