Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0158, written 15 May 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 15 May 2017 |
|---|---|
| Reference | 2017-0158 |
| Deceased | Stephen Leven |
| Coroner | R Brittain |
| Coroner area | London (North) |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. 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: The Rt Hon Jeremy Hunt MP, Secretary of State for Health, Department of Health, Richmond House, 79 Whitehall , London. 1 CORONER I am R Brittain, Assistant Coroner for Inner London North. 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 Stephen Leven died, aged 56, on 13 December 2016 from an intracerebral haemorrhage. The inquest into his death concluded on 10 May 2017; I recorded a conclusion of natural causes. 4 CIRCUMSTANCES OF THE DEATH Mr Leven had a significant past medical history of haemophilia for which he had been undergoing treatment at the Royal Free Hospital. He carried with him a card provided by this hospital, which set out the diagnosis and was intended to be presented to healthcare providers to inform them of the potential significance of the disease, as it related to other medical conditions. I heard from Mr Leven’s partner that she was not aware of his haemophilia diagnosis, despite having lived with him for a number of years. In early December 2016 Mr Leven developed a headache and changes to his visual field. On 7 December he presented to an optician who confirmed that there was a deficiency in his visual field and recommended that he present urgently to his GP for onward referral. Instead Mr Leven attended A&E that evening. He did not disclose to the A&E department his haemophilia diagnosis, nor did the clinicians there have access to GP information that would have contained information regarding this diagnosis. CT scanning demonstrated a large intracerebral haemorrhage and, after a deterioration which resulted in him being intubated and ventilated, he was transferred to a neurosurgical centre. I heard evidence from the neurosurgical consultant who treated Mr Leven that they also did not have access to GP records. Mr Leven underwent a neurosurgical procedure to treat the brain haemorrhage. As this procedure was finishing, information was provided by members of Mr Leven’s family that he had haemophilia. Appropriate treatment was provided but, unfortunately, he did not recover substantively. He died on 13 December 2016. 1 I heard evidence from the treating neurosurgeon that the fact Mr Leven did not disclose his haemophilia diagnosis did not cause or contribute to his death. This is one of the reasons I concluded that his death arose from natural causes. However, I was concerned that the treating clinicians did not have access to GP records which recorded the diagnosis of haemophilia. This is related to an issue I raised with the Department of Health in October 2015 (see attached report). The response (see attached) set out that access to the ‘Summary Care Record’ (SCR) was due to be implemented for ‘hospital acute admissions’ by March 2016. The response also stated that the provision of ‘enhanced summary care records’ was being developed, which would allow access to ‘special patient notes’. 5 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: I am concerned that, in different circumstances, the lack of access to GP information regarding Mr Leven’s diagnosis of haemophilia, could have caused or contributed to his death. As such, I am concerned that deaths could occur in future similar circumstances if further action is not taken to facilitate secondary care access to GP records. 6 ACTION COULD BE TAKEN In my opinion action could be taken to prevent future deaths and I believe that the addressee, has the power to take or may be actively undertaking 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 10 July 2017. 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 I have sent a copy of my report to the Chief Coroner, Mr Leven’s family, Royal Free Hospital, North Middlesex Hospital and the National Hospital for Neurology and Neurosurgery. 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 15 May 2017 2 Assistant Coroner R Brittain 3
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} Rt Hon Alistair Burt MP Minister of State for Community and Social Care Department of H ealth Richmond House 79 Whitehalf London SWI1A 2NS POC00001002339 “_™ Tel: 020 7210 4850 Mr R. Brittain Assistant Coroner St Pancras Coroners Court Camley Street 02 DEC 2015 London NIC 4PP Dew (NG Gre Hrucn | Thank you for your letter of 7 October 2015, following the inquest into the death of Edward Gascoigne. I was sorry to hear of Mr Gascoigne’s death and wish to extend my condolences to his family. _—_———, - This case highlights issues about the sharing of patient information within the NHS. You are rightly concerned about access to patient’s GP records by treating clinicians and indicated that you feel that the current system of record sharing in the NHS will pose risks to patient care. It is vital that the effective treatment of patients is underpinned by timely and appropriate transfer of key information that follows the patient through the healthcare system. The current system of sharing GP patient records is via the Summary Care Record (SCR). To date, more than 96% of people in England have had SCRs created and uploaded onto the NHS National Spine, a national infrastructure that stores electronic patient information. SCRs contain information sent electronically from the GP record to be held securely on the National Spine. Core data in all SCRs comprises: details of Medications (Long-term, Acute and recently discontinued), known Allergies and Adverse Reactions. This information is kept up-to-date in real time. In most SCRs, the Core data also contains the ‘date of last issue’ of medications, which gives an indication of whether the patient is taking the medication regularly. ae Department of Health for use by commissioners for all contracts for healthcare services other than primary care). To quote the relevant section: ‘23.6 Subject to General Condition 21 (Patient Confidentiality, Data Protection, Freedom of Information and Transparency) the Provider must ensure that all Staff involved in the provision of urgent, emergency and unplanned care are able to view key Service User clinical information from GP records, whether via the Summary Care Records Service or a locally integrated electronic record system supplemented by the Summary Care Records Service.’ In addition, NHS England’s business plan for 2015/16, which sets out priorities for the coming year, has mandated SCR access for 111 services, 999 services and hospital acute admission areas. To quote from the section, Commitments for redesigning urgent and emergency care services: ‘By March 2016 complete information sharing across 111, 999 and hospital acute admission areas to at least a minimum of Summary Care Record, including end of life and advanced care plans. . . ‘ Furthermore, NHS England is working with partners to develop a range of tools and guidance to support commissioners and providers in the transformation of urgent and emergency care services. This includes the development of an enhanced summary care record which will enable greater access to patient care plans, including end of life care records, special patient notes and mental health crisis notes. T hope I have reassured you that Government plans for sharing of patient information is a priority for urgent and emergency care and that the current SCR system is designed to improve access to patient’s GP records so that important and vital patient information is available to all treating clinicians. I am grateful to you for bringing the circumstances of Mr Gascoigne’s death to my attention and trust that you find this reply helpful. Fon neh Ah ALISTAIR BURT —~
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