Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0059, written 18 Feb 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 18 Feb 2015 |
|---|---|
| Reference | 2015-0059 |
| Deceased | Alan Jones |
| Coroner | Paul Bennett |
| Coroner area | Swansea Neath & Port Talbot |
| 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 (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. NHS Wales 2. NHS England 3. Royal College of General Practitioners 4. Welsh Assembly Government 1 | CORONER | am Paul Jonathan Bennett, assistant coroner, for the coroner area of Swansea & Neath Port Talbot 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" April 2011 | commenced an investigation into the death of Alan Vaughan Jones aged 63. The investigation concluded at the end of the inquest on 16" January 2015. The conclusion of the inquest was Addison’s Disease as a result of neglect 4 | CIRCUMSTANCES OF THE DEATH The deceased had Addison’s disease and required steroid replacement medication which had been prescribed by his GP. In early April 2011, he developed gastroenteritis. He suffered with diarrhoea and vomiting and was unable to take his oral medication. He became progressively weak and unable to get out of bed. He required intravenous steroid replacement. He had a telephone encounter with his GP who was unaware that he had been diagnosed with Addison's Disease. This was because the software program containing his data did not show it as a critical part of his medical history, when the consultation screen was opened. The system was the EMIS program. The GP would be required to scroll through the whole of the past consultations or open a particular tab in the program to have seen the entry. In the context of a telephone consultation of 4 minute duration this was not considered to be unacceptable medical care. Advice given by the GP was to maintain fluid balance and avoid dehydration. Had the GP known of the Addison’s and the inability to take essential medication, his advice would have been different. The deceased’s daughter met with a different GP that same day (7" April 2011) and did a review of the medical history. She was able to access the whole of the records, She identified his condition of Addison's disease, but did not make arrangements to visit the deceased at home that evening nor arrange for him to be admitted to hospital as an emergency. His condition deteriorated and he died at 08.50 hours on the 8" April 2011. 1 The evidence of the expert endocrinologist established causation, viz: that had he been admitted to hospital and received intravenous steroids ay any time up until midnight on the 7" April he would not have died. A short form conclusion of neglect was returned. 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. — The evidence of both of the GPs involved in Mr Jones’s care, as well as that of the GP expert, clearly highlighted issues with the use of the electronic data on the patient system. These were:- (1) An apparent lack of adequate training on the use of the software systems. This meant that important clinical information could not be made available easily. The expert GP gave evidence that this training deficit was not uncommon. He had the experience of using 4 different software programs in his career and had identical issues over lack of training. (2) An apparent failure in the software programs themselves to highlight important diagnosed conditions as an alert, when the patient record is opened and to prevent any further steps being taken to navigate the program (and make any entries) without consciously closing the “alert” first. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and ! believe you AND/OR your organisation has 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 22™ April 2015. |, 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:- I, The family of the late Alan Vaughan Jones. lam 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. 2
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.
AG Tamara Finkelstein Chief Operating Officer Department ii of Health Richmond House 79 Whitehall London SWIA 2NS Mr P. Bennett pe Assistant Coroner Coroner’s Office, Civic Centre, Oystermouth Road, Swansea. SAI 3SN 27 April 2015 Dear Mr Bennett, Thank you for your letter to Dame Sally Davies following the inquest into the death of Alan Jones. I was very sorry to hear of Mr Jones’ death and wish to extend my sincere condolences to his family. Mr Jones was a patient in Wales. You have sent your report to NHS Wales and the Welsh Assembly Government as the appropriate bodies to respond to your concerns in this case. In addition, the Royal College of General Practitioners will be interested in the issues you raise. The Department of Health in England has however no responsibility for operational matters for general practice in Wales. My comments therefore relate to the points you make about EMIS and GP record systems as they apply in England. Your concerns focus on both the capability and accessibility of EMIS as an electronic patient record system used in general practice, and the apparent lack of training for GPs in the use of this system and other such systems. Evidence given at the inquest clearly highlighted issues with the use of the electronic data on the patient record system: e A lack of adequate training on the use of the software systems. This meant that important clinical information could not be made available easily. The expert GP gave evidence that this training deficit was not uncommon. e A failure in the software programmes themselves either to highlight important diagnosed conditions as an alert, when the patient record is opened or to prevent any further steps being taken to navigate the programme (and make any entries) without consciously closing the “alert” first. In England GP practices have freedom to choose and implement their own IT systems and there are a number of GP systems available, including EMIS. This scheme is known as the GP Systems of Choice (GPSoC) through which the NHS funds the provision of GP clinical IT systems in England. GPSoC includes all the leading GP clinical IT systems in use in England. Following the introduction of GPSoC, practices can choose between systems provided either by their Local Service Provider (LSP) or by suppliers contracted to offer systems on the GPSoC Framework. The GPSoC Framework offers a number of benefits for GP Practices. e Greater choice of centrally and locally-funded IT systems and services ¢ Central funding for patient facing services required to meet GMS contract obligations. e Opportunity to hold Principal System suppliers to account, through GPSoC, for the delivery of service improvement plans. « Centrally-funded training for National Services such as the Electronic Prescription Service, GP2GP and the Summary Care Record. Further details about the GPSoC Framework and the systems available can be found on the GPSoC website: http://systems.hscic.gov.uk/gpsoc The GPSoC is also available in Wales. However I understand that Welsh requirements are not the same as English GPSoC requirements, with the result that, for example, alert and message functions may vary. I hope that this response is helpful and I am grateful to you for bringing the circumstances of Mr Jones’ death to my attention. Yours sincerely TAMARA FINKELSTEIN
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