Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0296, written 3 Sep 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 3 Sep 2018 |
|---|---|
| Reference | 2018-0296 |
| Deceased | Andrew Dickson |
| Coroner | Chris Morris |
| Coroner area | Manchester South |
| Category | Community health care and emergency services 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 THIS REPORT IS BEING SENT ‘oe -< Partners, Stockport Medical Group, Edgeley Medical Practice, 1-3 Avondale Road, Edgeley, Stockport SK3 9NX. CORONER lam Chris Morris, Area Coroner for Manchester South. 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. http://www legislation.gov.uk/ukpga/2009/25/schedule/S/paragraph/7 http://www. legislation.gov.uk/uksi/2013/1629/part/7/made INVESTIGATION and INQUEST On 2™ March 2018, Rachel Galloway, Assistant Coroner, opened an inquest into the death of Andrew Arthur Dickson who died on 15" February 2018 aged 30 years. The investigation concluded at the end of the inquest which | heard on 13" August 2018. At the end of the inquest, | determined that Mr Dickson sustained fatal injuries having jumped from a viaduct to his death. | recorded a conclusion of Suicide. CIRCUMASTANCES OF THE DEATH Mr Dickson was a relatively infrequent attender at his GP surgery, and had not until shortly before his death sought medical attention as a result of any concerns relating to his mental health. In the final week of his life however, those closest to Mr Dickson became profoundly concerned about him. On 12" February 2018, Mr Dickson’s mother persuaded him to consult with a GP and indeed sought to arrange an appointment on his behalf. The practice computer system records the rationale for her request (made by telephone to a receptionist) for an appointment as being “having suicidal thoughts for few days”. The evidence before the court was that this message resulted in the generation of an alert note on screen which the telephone triage doctor would see. Following telephone triage, an appointment with a GP took place later that day during which both Mr Dickson and his mother were present. The entry in Mr Dickson’s clinical notes relating to that consultation makes no reference to any discussion about suicidal thoughts, or indeed reference to the communication with the receptionist earlier that day. As a result of the consultation, the GP considered Mr Dickson appeared to be suffering from an anxiety disorder, which may have been exacerbated by drug use. Mr Dickson was signposted to the community drug team, encouraged him to see a counsellor and prescribed a course of sertraline, with accompanying advice as to the intended benefits and potential side effects of that medication. The GP also arranged for blood tests to be taken and put a plan in place to review Mr Dickson in a months’ time, once those results were available and the sertraline had sufficient opportunity to be effective. 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. — Notwithstanding the obvious significance of the information provided to the practice by telephone on 12" February 2018 when an appointment with a GP was sought on the basis that Mr Dickson had been having suicidal thoughts, the evidence before the court was that whilst this information is made available to the telephone triage doctor by way of alert note, the same text is not incorporated in to the screen which a doctor subsequently undertaking a face-to-face appointment sees. This raises the following matters of concern:- 1. The safety of the computer system as currently operated appears to be prefaced on the telephone triage doctor being the same clinician who sees the patient at a subsequent face- to-face consultation, and remembering the content of the alert note despite having had to undertake a multitude of other tasks in the meantime; 2. In the alternative, the onus is likely to fall on the patient (or his / her representative or carer) to repeat information in the course of the consultation which may already be in the practice’s knowledge as a result of an earlier telephone call to an administrative member of staff, and which the patient (carer or representative} is likely to assume is already in the doctor’s possession; 3. The system as currently operated appears likely to create additional risk in a group practice (in circumstances where the telephone triage doctor may be based in a different location from the doctor undertaking a subsequent consultation), and where patients may be vulnerable or reluctant to engage with a doctor for any reason. ACTION SHOULD BE TAKEN in my opinion action should be taken to prevent future deaths and | believe you and your organisation have 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 29" October 2018. |, 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 h on behalf of Mr Dickson’s family. | have also sent a copy to} f DAC Beachcroft LLP, solicitors to the Medical Defence Union. | have sent a copy of my report to Stockport Clinical Commissioning Group and the Care Quality Commission, who may find it useful or of interest. 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. Dated: 3" September 2018 4 Chris Morris Hi! Area Coroner, Manchester Sout Signature:
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.
we 17" October 2018 Dear Sir, RECEIVED Re: Andrew Arthur DICKSON 1 9OCT 2018 Your Ref: 9588/CH We write in response to your letter dated 3 September 2018 enclosing a Regulation 28 report following the inquest into the sad death of Mr Dickson. We note the matters of concern stated in the report and would like to outline the action Stockport Medical Group has opted to undertake in response in order to ensure patient safety in the future. The partners of the practice have discussed this matter at length and we accept the need for a robust system to record clinical information from reception or the triage list in the patient records. This information needs to be readily visible to any doctor that may then subsequently see the patient after a triage assessment, regardless of their location, to ensure a clear handover of clinical information and that an appropriate assessment is carried out. There also needs to be an audit trail, should there be a need for scrutiny as to individual actions and specific timeframes. Currently, the information recorded by receptionists in relation to triage calls is only visible to the triage doctor if he or she specifically finds the patient on the triage list and hovers over the slot with a mouse cursor. The information then briefly appears. This often includes a telephone contact number to help the doctor managing the triage list on that day. However, this information does not appear in the patient’s clinical records. The partners’ discussion centred around the need to achieve a balance between the need for all pertinent clinical information to be visible in the clinical records on the one hand, and the need to avoid unnecessary or administrative entries that can clog up the notes and may potentially make it more difficult for a clinician to be able to identify relevant clinical information. We decided that it would be unreasonable and potentially unsafe to expect staff taking these calls, who are not medically trained, to decide what information is clinically relevant. !t was therefore agreed that the practice should adopt a policy that all information recorded by reception staff from patients or carers’ initial calls, along with any subsequent notes made by the triage doctor, should be recorded in the clinical notes. These notes are available for clinicians to consult across all practice locations. We have instructed staff to use a template that we have added to EMIS for booking patients onto the triage list. An example of this system is enclosed. The template contains free text data which can be saved onto the clinical records. Since they do not contain coded problem headings, they can also be used by non-clinical staff. The only aspect that can be coded is if the patient is ‘signposted’ to other services such as community physiotherapy. Once saved, they are readily visible on the clinical notes and subject to an audit trail, should this be required. We have organised training with the reception supervisors in order to ensure that this new EMIS template is being used whenever patients are booked onto the triage list. This training is scheduled to take place over the next 4 weeks. Our reception supervisors will subsequently inform and train staff at each of our 3 sites, explaining that this is now the standard format for adding patients onto the triage list. We therefore expect that all notes will now appear on the EMIS clinical records. Our practice currently uses the EMIS Web clinical system which is used nationally. This system does not currently have the means to automatically pull information across from triage or appointment slots into the clinical notes. We consider that it would be preferable for this to be automated, removing the manual part of the process outlined above. We have written to EMIS on 21* September 2018 (reference ECR 10381933) requesting this addition to their software. We have highlighted why there is a need for this and the potential implications of an omission of this software capability, as clearly outlined in your letter. We recognise that software changes and improvements in systems of this scale may take some time. We intend to adhere to the above policy pending a suitable adaptation to the EMIS software. I trust the above is satisfactory. Please contact me if you require any further information on the measures we have implemented or this matter in general. This letter has been approved by all members of the partnership. Yours faithfully, Stockport Medical Group cc CQC and CCG
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