Prevention of Future Deaths reports · 2017

Rose Ball

Regulation 28 report to prevent future deaths, reference 2017-0395, written 14 Nov 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report14 Nov 2017
Reference2017-0395
DeceasedRose Ball
CoronerHeidi Connor
Coroner areaNottinghamshire
CategoryCommunity health care and emergency services related deaths
Sourcejudiciary.uk record · original PDF
Responses publishednone published

The report

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.  Head of GMC Fitness to Practise Team :  practise@gmc-uk.org 

1 

CORONER 

I am Mrs Heidi Connor, assistant coroner for the coroner area of Nottinghamshire. 

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 12 September 2017 I commenced an investigation into the death of Rose Ball, aged 
82. The investigation concluded at the end of the inquest on 7 November 2017. The 
conclusion of the inquest was natural causes. 

4 

CIRCUMSTANCES OF THE DEATH 

The family asked me to refer to their mother as Rose during the inquest. I reflect that 
request in this report. 

Relevant evidence 

Rose had no significant past medical history relevant to the cause of death. She was not 
a regular attender at the GP practice, Riverlyn Medical Practice. Bulwell in Nottingham. 

Rose reported concerns to her GP about pain in her upper tummy and back on 9 June 
2016. She was prescribed Lansoprazole and Gaviscon. She confirmed the following day 
that she felt better. Both of these interactions are clearly recorded as telephone 
consultations. These records are those of 

. 

Rose spoke to her GP again on 6 and 7 December 2016. Both of these interactions 
were with 

.  

Neither record mentions the fact that these were telephone consultations.  In fact, the 
record of 6 December includes the following : 

“Examination : no pain abdomen” 

 prescribed Omeprazole. There is no record of safety-netting advice. There 

is no record of a plan to see the patient. I did not accept 
above record, namely that he was recording the patient’s examination of her own 
abdomen. 

 explanation for the 

The following day, Rose’s son attended the practice. He begged 
examine his mother. 
 again telephoned her, this time diagnosing a likely upper 
respiratory tract infection. He prescribed Amoxicillin tablets. There is no record of safety-
netting advice or any plan to see or examine the patient. There is no record of routine 
observations at either appointment – these were clearly impossible as both 
appointments were by telephone. I found that 
despite his assertions to the contrary in court. 

 had no plan to examine Rose, 

 to attend to 

Sadly, Rose’s condition deteriorated. She was admitted to hospital in the early hours of 
8 December, and died later that day. 

1

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Her cause of death (following a PM) was :  

1a Acute peritonitis 
1b Perforation of Duodenum 
1c Duodenal erosions 
2 Ischaemic heart disease 

I found that the duodenal perforation is unlikely to have happened before the GP’s 
involvement on 6 and 7 December 2016. I also concluded that it may well be the case 
that different management by the GP may not have changed the outcome, given Rose’s 
age and co-morbidities. 

My focus in drafting this report is on those patients for whom the failure to examine them 
– and the managing of conditions wholly by telephone – could mean the difference 
between life and death. 

Previous investigations 

NHS England 

This matter has been the subject of a family complaint. NHS England carried out an 
independent clinical review into this death and that of her husband just the day before. 
The entry relevant to this case states : 

“With regards to the entry on 7.12.17 [sic] pertaining to Mrs Ball there is very little detail 
pertaining to the clinical history and no routine observations or clinical findings are 
recorded….” 

It is clear that the reviewer considered 
the appointment of 7 December was a face to face consultation.  The records clearly 
give that impression. 

 management on the assumption that 

I was concerned to note also that it appears 
the investigation. He is described as “very concerned to outline the good care Mrs Ball 
was having”. I do not know what the protocol is for doctors who are the subject of 
investigations ringing  up to ‘put their case’ in this way. It would seem that that 
discussion did not include the fact that the consultations on 6 and 7 December were 
both by telephone. 

 contacted the case handler during 

 has subsequently written to NHS England (in a letter dated 20.3.17). In it, he 

sets out his plan of action for improvements. In the chronology, he does refer to the 
consultations of 6 and 7 December 2016 as being by telephone. This does not appear to 
have been picked up on by NHS England. 

It may be that NHS England will wish to review this case in light of the evidence of this 
inquest. They may also wish to re-examine their method of clinical review and consider 
whether a paper exercise is sufficient in all cases. It is not unreasonable to assume, 
based solely on the records for these examinations, that they were face to face 
examinations. 

CQC 

This practice has been subject to CQC concern. The practice was inspected on 4 
January 2017, to follow up a warning notice (issued following an inspection in August 
2016). One of the issues identified was systems for managing complaints and significant 
events. 

The practice has recently re-registered – in August 2017. 
that he had been told by the CQC that both he and 

 gave evidence 
 need to be registered 

2

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 providers before the CQC can carry out its first inspection. 

The full details of CQC involvement are publically available on their website.  

I invite the CQC to expedite their inspection of this practice in view of the findings of this 
inquest. 

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. 

1. 

2. 

3. 

4. 

5. 

 failed to record that the consultations of 6 and 7 December were by 

 evidence in court that he considered  his only 

telephone – and in fact recorded an abdominal examination that never took 
place. 
I was troubled by 
failing was in relation to record-keeping. 
It is clear that 
referred to a pattern of diagnoses by telephone by this practice. I hold records 
from January 2015 onwards only. It is possible that this pattern may be repeated 
earlier in this patient’s records – or perhaps in the records of other patients. 
I invite you to consider the fitness to practice of 
findings of this inquest. 
I strongly urge the recipients of this report to listen to the recording of this 
inquest. This can be supplied electronically (via Cryptshare) or on a CD. 

 conduct goes well beyond poor record-keeping. I have 

, in view of the 

The fact that a Regulation 28 report has been issued to the GMC should not be 
interpreted as a criticism of that organisation. This point has been made clearly in the 
case of R (Dr Siddiqui and Dr Paeprer-Rochricht) v Assistant Coroner for East 
London. 

I have raised my concerns using Regulation 28 of the Coroners Investigations 
Regulations 2013 in view of the serious nature of the concerns I have, and in view of 
the fact that previous NHS investigations have already taken place and not brought 
the telephone consultation point to light. I consider this a matter of concern for wider 
public safety. 

For the avoidance of doubt, whilst I would welcome replies from NHS England and 
the CQC to the issues I have raised, a formal response to this report is required only 
from the GMC. 

6 

ACTION SHOULD BE TAKEN 

In my opinion, action should be taken to prevent future deaths and I believe you / 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 9 January 2018. 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. 

3

 
 
 
 
 
 
 
 
 
 
 
 
 
 8 

COPIES and PUBLICATION 

I have sent a copy of my report to the Chief Coroner and to the following Interested 
Persons :  

1.  Rose’s family 
2. 
3.  CQC 
4.  LMC 

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 

14.11.17                                              H.J.Connor 

4

Related reports

Other reports by Heidi Connor

See all →

More reports categorised “Community health care and emergency services related deaths”

See all →

Track Community health care and emergency services related deaths

See every Prevention of Future Deaths report matching Community health care and emergency services related deaths, and how often a new one appears.

What would an alert for this have sent me? Search the full text

Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.

These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.