Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0451, written 21 Oct 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 21 Oct 2015 |
|---|---|
| Reference | 2015-0451 |
| Deceased | David Baddeley |
| Coroner | Joanne Kearsley |
| Coroner area | Manchester South |
| 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 FI UTURE DEATHS THIS REPORT IS BEING SENT TO: Medical Director of the Greater Manchester NHS Area Team CORONER Tam Joanne Kearsley Area Coroner for Manchester South 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 I. 3 | INVESTIGATION and INQUEST On the 6” October 2015 I concluded the Inquest into the death of David Baddeley date of birth 29.04.1972 who died on the 23.06.2015 at his home address 54 Chester Avenue, Dukinfield, Tameside, The cause of death was 1a) Hanging 2) Schizophrenia I recorded that the deceased had a history of Schizophrenia. At the time of his death he was not being prescribed his anti-psychotic medication, He died as a result of tying a ligature around his neck, at his home address. It is probably he was suffering from a deterioration in his mental health at the time he died. [ reached an Open Conclusion as there was no evidence the deceased had intended to end his own life. Kt 4 | CIRCUMSTANCES OF THE DEATH As indicated Mr Baddeley, an extremely intelligent gentleman, had a very long standing diagnosis of Schizophrenia which was controlled With anti-psychotic medication. He had had a number of hospital admissions throughout his life. For the majority of his life Mr Baddeley had lived in the Tameside area. Approximately 4 years ago he moved to the Stockport area. He had a GP in Cheadle. Whilst in Stockport he had a number of admissions to Stepping Hill Hospital. His last admission being in 2013. In around September 2014 the Court heard evidence that the deceased moved back to the Tameside Area. He registered with the Ann Street Medical Practice in Denton and first attended the surgery in September 2014 for an unrelated condition. At this stage his manual records were not with the practice as these did not arrive until at least a month after he had registered. Due to the volume of patients and medical records the Court heard that it was not until the 9" March 2015 that a summary of his medical records was completed. Even then it was not clear that this was a patient with an underlying mental health condition. On the 30 March 2015 Mr Baddeley made an appointment with the practice and requested a repeat of his Amisulpride medication which he advised he was taking twice a day, although he did indicate he had reduced his dose due to side effects. At this stage his GP advised he would contact his Previous Psychiatrist for further information as it was not possible from the information available to determine when he had last been seen. He also prescribed his Amisulpride medication for a period of 4 weeks. The Court heard that the information from the psychiatric services was not received until the 6"" May 2015. However on the 1° May Mr Baddeley had attended the practice and advised the practice nurse that he had moved and would be registering with a new practice closer to where he now lived. On the 12" May he registered with the Davaar Medical Centre in Dukinfield and his records from Ann Street had been forwarded electronically, The Court heard that whilst the medical records are sent electronically GPs are not aware of which practice they are sent to. The Court heard that if the GP had known the details of the practice Mr Baddeley had registered with he would have spoken to them about his mental health issues and the fact that he appeared no longer to be under psychiatric services and was not receiving his anti-psychotic medication (save for the one prescription issued on the 30" March). The Court also then heard from a GP from the Davaar Medical Practice. He advised the Court that due to the fact that medical practices are on different computer systems, when Mr Baddelys’ electronic records were received the fact that he was diagnosed with Schizophrenia was not obvious in the format they were received. On the 18" May Mr Baddeley attended for a new patient check and was seen by a Healthcare assistant, but this was limited and the Court heard that the Healthcare Assistant would not have been expected to have read all the electronic records which had been received. The Davaar Medical practice did not receive Mr Baddeleys written records until the 28" May 2015, these were not reviewed until the 15" June. When they were reviewed they were detailed as not requiring any action. CORONER’S CONCERNS The concerns noted by the Court during the course of the Inquest are as follows: 1) That the transfer of a patients electronic records between medical practices can mean that key information is not highlighted due to the incompatability of the systems. 2) The practice which a patient is leaving is not notified of the new practice taking over the patients care so that doctors can speak and discuss any pertinent medical issues. 3) The length of time it takes for a medical practice to receive the full paper medical records. 4) Due to the volume of work the fact that it takes 8 weeks for a patients paper medical records to be reviewed and summarised. 5) The fact that the initial new patients health Screenings did not note that Mr Baddeley had a serious psychiatric illness, which could have made him a risk to himself or indeed others as he was not taking his antipsychotic medication. 6) That when his paper records were reviewed on the 15" June nothing pertinent was thought required and again his mental health diagnosis and lack of medication not picked up. 6 | ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. It should be noted that both of the medical practices involved in this particular case had themselves noted flaws in the systems and taken steps to address some of the issues themselves, however the findings of the Court highlight an issue which may impact on medical practices across Manchester. | YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 16th December 2015 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. 8 | COPIES and PUBLICATION Ihave sent a copy of my report to the Chief Coroner and to the following Interested Persons namely, the family of Mr Baddeley. I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both ina 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. - 21.10.2015 Joanne Kearsley Area Coroner
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.
Miss J Kearsley Area Coroner Coroner's Court 1 Mount Tabor Street Stockport Se > 201S OFFICIAL-SENSITIVE: PERSONAL NHS England GB Medical Directorate NHS England - North Lancashire & Greater Manchester 4" Floor 3 Piccadilly Place SK1 3AG ! Manchester M1 3BN 0113 825 5149 patel@nhs.net 03 December 2015 Dear Miss Kearsley Regulation 28 Report — Mr David Anthony Baddeley Thank you for your Regulation 28 Report regarding the death of Mr David Anthony Baddeley and the concerns with regard to avoidable harms. 1; NHS England, GPs and Clinical Commissioning Groups have also identified the risks to patients where records do not make obvious the key diagnoses, blood tests, allergies or other significant clinical matters. Since the advent of the new GMS contract, circa 2004, Primary Care practices have been incentivised and contracted to apply accurate electronic READ coded items (READ codes are fixed and specific codes used to record patient diagnoses, blood test results, allergies and so on within the Clinical system). GP contract terms require IT systems to be approved and demonstrate compliance to these IT standards. Where records are transferred electronically, the READ codes are to be used by the recipient practice to establish for themselves, in conjunction with any medical records summary, the clinical needs and concerns relating to that patient. The sending practice has a data governance obligation in ensuring accuracy. Today, the electronic transfer of patient records within England takes place using GP2GP. This is the consistent single tool for practices to transfer all READ coded items automatically to the receiving clinical system. All narrative data is also transferred. This occurs regardless of the computer system used, providing that both of the practices are GP2GP enabled (currently 98% of GP practices in England have GP2GP capability). | can confirm that the two practices involved are GP2GP enabled. High quality care for all, now and for future generations OFFICIAL-SENSITIVE: PERSONAL 14. NHS England has recently procured Capita to manage it’s Primary Care Support Services. One of the work streams is the management of medical records. From June 2016 it is planned that practices will be able to track records and see expected delivery dates. In the meantime, practices can, when necessary, request paper records urgently. 15. Electronic records can be summarised in the usual way at the receiving GP practice. If there is a concern about a patient, the practice may prioritise the summarising of a particular set of notes, usually at the request of the clinician who may be looking after them at new practice, especially if it is felt that the patient may have a complex medical history. 16. Note summarising was included as part of the national GP contract as part of the Quality and Outcome Framework. This ceased at the end of 2012/13 when it was retired on the grounds that it was standard good practice and would be maintained. This standard for this indicator was that 80% of newly registered patients had their notes summarised within 8 weeks of receipt by the practice. 17. Practices will be reminded to ensure that when patients are seen at new patient health checks that they are screened for serious psychiatric illness. 18. Practices will be reminded to ensure that when a patient deregisters and transfers to another practice, that the patient record, both electronic and paper, should be checked to ensure that significant diagnoses are recorded, highlighted and correctly coded. My apologies for the small delay in sending this response. This response is on behalf of NHS England Lancashire and Greater Manchester. | have shared this letter with the North of England Medical Director to learn if this response can be on behalf of NHS England more widely. | am awaiting a response. Yours sincerely Dr Raj Patel Medical Director, Lancashire & Greater Manchester Director of Commissioning, Lancashire
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