Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0073, written 7 Mar 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 7 Mar 2018 |
|---|---|
| Reference | 2018-0073 |
| Deceased | Ivanika Olivari |
| Coroner | Fiona Wilcox |
| Coroner area | London Inner (West) |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
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 FUTURE DEATHS THIS REPORT IS BEING SENT TO: Miles Scott, Chief Executive, St George’s Hospital, Blackshaw Road, London. SW17 0QT Charlie Massey, Chief Executive, General Medical Council, Regents Place, 350 Euston Road, London. NWE1 3JN The Rt Hon Jeremy Hunt MP, Secretary of State for Health & Social Care, Department of Health, 39 Victoria Street, London. SW1H 0EU 1 | CORONER | am Dr Fiona J Wilcox, HM Senior Coroner, for the Coroner Area of Inner West London 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 the 19" October 2017 and 21% February 2018, evidence was heard touching the death of Ms Ivanika Olivari. Ms Olivari had died on 3 August 2017 in St George’s Hospital following an out of hospital cardiac arrest at her home address on 29" July 2017. She was 68 years old at the time of her death. The findings of the court were as follows: Medical Cause of Death 1 (a) Hypoxic-ischaemic encephalopathy secondary to ventricular fibrillation cardiac arrest (b) Malfunction of implanted cardiac pacemaker (c) Atrial Fibrillation II Mitral valve replacement for mitral stenosis, pulmonary hypertension, systemic hypertension and rheumatic fever. How, when and where the deceased came by her death: Ms Olivari suffered with heart problems following rheumatic fever including an arrhythmia for which she had an implanted pacemaker. On 29" July 2017 a Holter recording found her pacemaker to be malfunctioning. This required urgent resetting to prevent the risk of her developing a life threatening arrhythmia. An unsuccessful attempt was made to contact her by telephone at approximately 13:25. Ms Olivari arrested at approximately 18:13 the same day as a result of the pacemaker malfunction. She was resuscitated at the scene, taken to St George’s Hospital and her pacemaker reset. Sadly she died on 3/8/2017 as a result of neurological damage sustained at the time of the arrest. Conclusion of the Coroner as to the death Natural Causes Circumstances of the death. Evidence was taken at the inquest that the problem identified on the Holter recording was that the pacemaker was not correctly capturing the heart beat of MS Olivari, such that she had pauses with no heart rhythm which made her susceptible to the . development of escape ventricular fibrillation. This was found at the scene by the LAS when she collapsed at home. This was considered by the clinicians who gave evidence to be a real and significant and life threatening risk. However as she had not reported any physical symptoms during pauses.on the Holter recording, this risk whilst real, was considered to be unlikely to imminently occur. As such Ms Olivari was classified as requiring urgent treatment, within the next few hours to reset her pacemaker, but not immediate emergency treatment. The results of the Holter were brought to the urgent attention of the Cardiology registrar on call who then pulled up her electronic records and made two attempts to call the number on the records given as Ms Olivari’s mobile phone through the hospital switch board. One call lasted 17 seconds and one 25 seconds. This doctor could not recall the two calls connecting, but recalled getting through to the mobile’s answerphone on one occasion. She stated that she did not leave a message on the phone, but intended to try and call her back later and if by the end of her shift, which was a very busy Saturday due to finish at 8 pm, she had made no contact, then she would arrange for an ambulance to be sent to Ms Olivari’s home address to collect her and bring her to hospital to have her pacemaker re-set. No other numbers were used to try and contact Ms Olivari. In the event, this doctor did not attempt to contact Ms Olivari again and at approximately 19:30 Ms Olivarui was brought to St George’s Hospital by the LAS who had resuscitated her at home following her collapse at around 18:13. A finding of fact was made that had Ms Olivari been contacted and attended hospital and had her pacemaker re-set prior to her arrest she would not have arrested and died at the time she did. The cardiology registrar stated that she did not leave a message as she had concerns about patient confidentiality and to leave a message was against what she understood to be hospital guidelines. The Court was informed that hospital guidelines on message taking were based on guidelines from the department of health and the GMC which concern possible breaching of patient confidentiality. Not even a very bland and non-contentious message was left, advising the patient to contact the cardiology registrar, whom had previously seen and been in communication with the patient and so was known to Ms Olivari. CORONER’S CONCERNS During the course of the inquest the evidence revealed maiters 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. It is for each addressee to respond to the matters that relate to their area of authority or control. The MATTERS OF CONCERN are as foliows: 1. That doctors should leave messages on answerphones for patients to make contact with them in urgent and emergency situations. 2. That doctors should attempt to contact patients via all contact phone numbers that they have access to for patients in urgent and emergency situations. 3. That in urgent and emergency situations risk to life should be considered the priority. 4. That hospital guidelines and St George’s hospital guidelines in particular, in relation to such matters, should be updated and amended to reflect the above where needed. 5. That hospitals and St George's Hospital in particular, should ensure that all relevant staff have their training updated in a prompt and auditable fashion to reflect the concerns raised above. 6. That the GMC considers its guidance for doctors and amend where necessary to ensure that it is clear that messages may be left for patients in urgent and emergency situations. 7. That the Department of Health also considers its guidance that it issues in relation to such matters, and amend where necessary to ensure that it is clear that | messages may be left for patients in urgent and emergency situations. 8. That the GMC and Department of Health both take steps to ensure that the clarifications as outlined above are communicated to all doctors by the GMC and to all relevant staff employed by the NHS by the Department of Health. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you [AND/OR your organisation] have the power to take such action. It is for each addressee to respond to matters relevant to them. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report. |, 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; Consultant Cardiologist, St George’s Hospital, Blackshaw Road, London. SW17 OQT. ardiology Registrar, c/o the Legal Department, St Goerge's Hospital, Blackshaw Road, London. * SW17 0QT. | 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. 7 March 2018 Dr Fiona J Wilcox HM Senior Coroner Inner West London Westminster Coroner’s Court 65, Horseferry Road London SW1P 2ED
2 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.
General
Medical
Council
, . th _ . . . Regent's Place
April 30" 2018 . . - - 350 Euston Road
: i : . . . London NW1 3JN
Dr. Fiona J Wilcox . . Email: gmc@gme-uk.org
.HM Senior Coroner ue Website: www.gimc-uk.org
Inner West London’ oe : "Telephone: 0161 923 6602
} a : : Fax: 020 7189 5001
Westminster Coroner's Court‘ mo
65, Horseferry Road
London, SW1iP 2ED
Investigation and Inquest into the death of Ms Ivanika Olivari
Dear Dr Wilcox,
We are very sorry to hear about the death of Ms Ivanika Olivari and have taken
time to consider the concerns and issues raised in the report. I will address each of
the points for the General Medical. Council (GMC) in turn.
° The GMC considers its guidance for.doctors and amend where
hecessary to ensure that it is clear that messages may be left for
patients in urgent and emergency situations.
_As you may know, one of the roles of the GMC is to describe what good medical
practice looks like, and to set out the professional values, knowledge, skills and
behaviours required of all doctors working i in the UK. ,
We do this in a document called Good medical practice (2013) which is supported
by explanatory guidance covering an extensive. range of issues.:The guidance is
necessarily expressed as high level principles as it applies to all doctors, in all
‘specialties, and across the four countries of the UK. It applies to all registered
doctors, whether or not they hold a licence to practise and regardless of their
Speriatys grade or area of: work (for example, NHS. or [rdependent practice).
’ In Good medical Dractice_ we explain that doctors must take prompt action if they
think that a patient's safety, dignity or comfort may be seriously compromised,’
(paragraph 25). ; . _
The GMC is a charity registered in
Working with doctors Working for patients 8 england ond Wales (1009278)
and Scotland (SC037750) ~
dn Confidentiality: Good practice in handling patient information (2017) we advise ©
_ doctors on communicating with patients. In this guidance we advise doctors to
communicate with patients in a format that suits both the patient and the situation — |
as long as appropriate safeguatds are put in place (paragraph 132). This can © ~
include voicemails: At paragraph 133 we expand on this to specifically address the.
~ Issue of voicemail messages and confidentiality as follows;
© Most communication methods pose some risk of interception — for example
messages left on answering machines can be heard by others and emails
can be insecure. You should take reasonable steps to make: sure the
communication methods you use are secure.
_ Given the nature and remit of our guidance, we do not give further procedural :
advice on what specific.steps doctors should take when weighing. up whether to i
leave a voicemail message, or what its contents should be. However the guidance
is clear that while confidentiality is an important and legal duty it, is not absolute
and the safety of patients must be taken into account. In line with.the general -
approach in the guidance, a decision not to leave a’ message would need to be i
. balanced against the harm (or lack of benefit) to the patient in delaying |
communication and perhaps further treatment as a consequence. a) 7 ; |
Whilst our guidance provides doctors with a framework from which to work within,
. _we.do expect doctor's to exercise their own professional judgment to apply the
oo principles to the situations they face in practice, and to be able to justify their ©
decisions and actions. All our ethical guidance is available at www. ginc-uk. Org.
e: That the GMC and the Department of Health both take steps to
. @nsure that the clarifications as outlined above are communicated
to all doctors by the GMC and to all relevant staff employed by the
NHS by the Department of Health.
We have recently faunched an‘updated interactive website ( WWW. w.gme-uk. org) and.
“are working on extra resources to expand our ethical guidance hub and learning
materials for doctors. We also have an extensive social media platform. We are
currently: considering how best to use these communication channels to remind -
doctors of their duty to take prompt action if they think that a patient's safety,.
dignity or comfort may be seriously compromised and.the communication methods
that may be available to do this.
We will also alert the Information Governance Alliance (which is the authoritative /
source of advice and guidance about the rules on using and sharing information in |
_ health and care in England) to the absence of guidance for NHS staff on the u use of
voicemail.
The GMC is a charity registered in
Working with doctors Working fer patients —— England and wees (1089278)
and Scotland (SCO37750)
i
|
-Ido hope this information is helpful to you, ify you need: any further. information,
please-don’t hesitate to get in touch with me.
‘Yours faithfully
Head of Strategy and Planning — Standards & Ethics ‘Team
General Medical Council —
Regent's Place, 350: Euston Road,
London NW1 3JN
Tel! 020 7189 5367
~ Email: fionnula.flannery@gmc-uk.org
England and Wales (1089278)
_ Working with doctors Working for patients THRGMC sa chy teed in
and Scotland {sco3775 0)
St George's University Hospitals INHS NHS Foundation Trust St George’s University Hospitals NHS Foundation Trust Blackshaw Road London SW17 0QT Dr Fiona Wilcox H.M. Senior Coroner for Inner West London Westminster Coroner's Court 65 Horseferry Road London SW1P 2ED 30 April 2018 Dear Ma’am Re: The late Ms Ivanika Olivari | am writing in response to the Prevention of Future Deaths report that you issued jointly to St. George’s University Hospitals NHS Foundation Trust, the General Medical Council and the Secretary of State for Health and Social Care following the inquest touching the death of Ms. Ivanika Olivari which took place on 19 October 2017 and 21 February 2018. | note that the matters of relevance to St George’s are set out at paragraphs 1-5 under “Coroner's Concerns”. For ease of reference, these concerns are: 1 That doctors should leave messages on answerphones for patients to make contact with them in urgent and emergency situations 2 That doctors should attempt to contact patients via all contact phone numbers that they have access to for patients in urgent and emergency situations 3 That in urgent and emergency situations risk to life should be considered the priority 4 That SGH hospital guidelines in relation to such matters should be updated and amended to refiect tiie above where needed. 5 That SGH should ensure that all relevant staff have their training updated in a prompt and auditable fashion to reflect the concerns raised above. The relevant Trust policy document that covers communications with patients is the Trust's Confidentiality Code of Conduct which falls within the remit of the Information Governance office, with the Executive sponsor being by Dr Mark Hamilton in his role as Excellence in specialist and community healthcare Associate Medical Director and Caldicott Guardian. The policy applies to all staff and the current version of this document was issued in March 2017 with a review date set for March 2019. The relevant section of the policy which makes specific reference to contacting patients by telephone is within Appendix 1 of the document. The guidance given to staff in the scenario where a phone call is not answered or where an answerphone kicks in is to ring back. There is specific instruction to staff not to leave a message on an answerphone. The reason for this instruction was to ensure that messages to call back a clinic or a clinician does not inadvertently compromise the privacy of a patient should the message be picked up by an unintended recipient. However, in light of the concerns you raised in the PFD report, we have made immediate changes to the guidance in Appendix 1 relating to leaving telephone messages, as follows: Contacting patients by phone Where the patient does not answer the telephone and there is no answerphone facility, you should make attempts to ring back. Such attempts should be noted in the patient's notes or logged elsewhere, with dates and times, wherever possible. Where the call triggers an answering message with a facility to leave messages, staff may leave a brief message requesting a call back, if the reason for ringing the patient is not urgent. Messages must be suitably worded so as not to divulge any personal data as defined in section 3.1 of this policy. In an urgent or emergency situation, staff must leave a brief message requesting a call back, being careful not to divulge any personal data. In an urgent or emergency situation, staff should make further attempts to contact the patient via any other contact phone numbers that they have access to for these patients. In an urgent or emergency situation, the risk to life should be prioritised and every attempt made to leave an appropriately worded message for the patient fo to contact the team caring for the patient. We hope you will agree that the above change in the guidance now given to staff has fully taken on board the concerns you raised in paragraphs 1 — 3. In respect of paragraph 4, as explained above, Appendix 1 of the Confidentiality Code of Conduct policy has been amended to reflect the concerns you raised to enable staff to leave telephone messages for patients in urgent and emergency situations. Having to review and amend Appendix 1 of the policy has presented an opportunity for the Information Governance office to bring forward the scheduled review date of the whole policy document to reflect the changes in the new General Data Protection Regulations. The updated policy will go through the relevant policy stages and will be published by autumn of this year. In the meantime, the updated Appendix 1, together with the learning from this case, has been disseminated throughout Cardiology services, and is due to be reported to the next Patient Safety and Quality Committee meeting in May and communicated to the wider organisation via the communications department thereafter. Excellence in specialist and community healthcare The changes in the policy will also be highlighted at the Information Governance Committee meetings and in all Information Governance training sessions. A link to the policy will be easily available to all staff through the Information Governance intranet pages. | hope, with these measures, that you are reassured that the matters of concern that you raised subsequent to the inquest have been taken very seriously by the trust and that we have taken immediate action to ensure that the policy is updated to address your concerns and all staff are made aware of the change in guidance in relation to leaving telephone messages for patients in urgent and emergency situations. Please do not hesitate to contact me if | can be of further assistance or if you have any residual concerns. Yours sincerely Jacqueline Totterdell Chief Executive Excellence in specialist and community healthcare
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