Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0149, written 2 May 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 2 May 2019 |
|---|---|
| Reference | 2019-0149 |
| Deceased | Alexander Davidson |
| Coroner | Laurinda Bower |
| Coroner area | Nottinghamshire |
| Category | Child Death (from 2015) · Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
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: IPs: Alex’s family DHU 111 (East Midlands) CIC Sherwood Forest Hospitals NHS Foundation Trust CQC For Action By: NHS Pathways The Roundwood Medical Practice, Mansfield, Nottinghamshire NHS England NICE For information only to: Chief Coroner Department for Health NSCB Mansfield and Ashfield CCG CORONER I am Laurinda Bower, HM Assistant Coroner for Nottingham City and Nottinghamshire 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. http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made 1 2 3 INVESTIGATION and INQUEST On 27 August 2018, I commenced an investigation into the death of Alexander James Davidson. The investigation concluded at the end of an inquest heard over two days on 4 and 5 March 2019. The conclusion of the inquest was that Alex died as a result of natural causes from: 1a. Multiple Organ Failure & Peritonitis 1b. Infected Pancreatic Pseudocyst (Operated) 1c. Gallstone Pancreatitis 2. Steatosis of the Liver; Ischaemic Bowel; Elevated BMI > 30kgm-2 CIRCUMSTANCES OF DEATH 4 Alexander James Davidson was born in Sutton-in-Ashfield, Nottinghamshire, on 5 August 2000. He was aged 17 years and 6 months when he died at the Queens Medical Centre on 26 February 2018. Alex was previously fit and well before suddenly taking ill with abdominal pain on 17 January 2018. Between that date and his admission to the Queens Medical Centre on 8 February 2018, Alex made contact with his GP on three occasions, had four telephone triage assessments undertaken by the NHS 111 service and two admissions to his local Accident & Emergency Department at the Kingsmill Hospital, ##DW<<corAddress>> Tel ##DW<<corTel>> | Fax ##DW<<corFax>> Mansfield. Alex’s symptoms of sudden onset acute abdominal pain, tachycardia, and vomiting and diarrhoea were attributed either to stress or to a bout of gastroenteritis. At no stage prior to 8 February 2018 was gallstones or pancreatitis considered as a differential diagnosis. When Alex was eventually admitted to the Queens Medical Centre Emergency Department on 8 February 2018, he was found to be septic as a result of an infected and necrotic pancreatic pseudocyst, which had evolved as a complication of gallstone pancreatitis, a rare condition in someone of Alex’s age. Despite medical intervention, Alex did not survive. The inquest explored the medical treatment and intervention that Alex received in the six weeks prior to his death. The medical evidence concluded that the pancreatic pseudocyst had likely formed by the time Alex began vomiting on 18 January 2018, and from that point onwards, it was unlikely he would survive even with treatment on account of the high mortality rate associated with this condition. 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. – (1) The NHS 111 telephone triage service uses the NHS Pathways computer system to triage patients via pre-determined question/answer based algorithms. The pre-determined questions are the same whether the caller is an adult or a child. Alex struggled to comprehend some of the medical terminology used during these calls. Call handlers are not permitted to deviate from the prescribed wording of the pre-determined questions, and this created confusion and inconsistency in the patient’s answers. Consideration should be given as to how young and/or vulnerable patients can be assisted to provide accurate information about their symptoms. (2) The NHS Pathways algorithm for triaging vomiting and diarrhoea symptoms is unclear as patients may fail to understand what is meant by ‘soil’ or ‘coffee ground’ vomit. Consideration should be given to how this important diagnostic feature can be explored during telephone triage, especially when the patient is young and/or vulnerable. (3) The NHS 111 telephone triage service provides an electronic copy of the patient triage notes to the patient’s GP within minutes of the call ending. There was a delay of 7 days in the GP surgery uploading the 111 triage document to Alex’s patient record. This prevented Alex’s GP from reviewing the triage note prior to his consultation with the patient. There is no guidance as to expected practise with regards to the timely updating of electronic patient records, and as a result delays are all too frequent. (4) Adults presenting to their GP or Emergency Department with abdominal symptoms receive a lipase and/or amylase blood test as part of the standard package of blood testing. The levels of each of these enzymes can be used to diagnose pancreatitis. Patients under the age of 18 years are not offered this testing as standard, on the basis that pancreatitis is rare in paediatric patients. I heard anecdotal evidence of some doctors at Kingsmill Hospital now add this test to the standard admission bloods for older teenage patients who present with non-specific abdominal symptoms but the NICE guidance (September 2018) is not explicit in this regard. I heard evidence as to the increasing prevalence of gallstone pancreatitis in young people, in line with an increase in childhood obesity. Consideration ought to be given to a national approach for lipase/amylase testing in young people with relevant symptoms. (5) Patients who make an unscheduled return to the Emergency Department within 72 hours of discharge are required to have a review undertaken by an ED Consultant, or a ST4 trainee or above in the absence of a Consultant on the ‘shop floor’: RCEM Guidance June 2016. Some hospitals will admit returning paediatric patients for observations but practise seems to vary doctor-to-doctor and across Trusts. Consideration ought to be given to a national approach. ##DW<<corAddress>> Tel ##DW<<corTel>> | Fax ##DW<<corFax>> 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 action in relation to the above matters (in numerical order), as follows: (1) NHS Pathways (2) NHS Pathways (3) The Roundwood Medical Practice, NHS England (4) National Institute for Clinical Excellence (5) National Institute for Clinical Excellence 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 25 June 2019. 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 In addition to the organisations identified in section 6 above, I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: Alex’s family DHU111 (East Midlands) CIC Sherwood Forest Hospitals NHS Foundation Trust Care Quality Commission and to the Nottingham Safeguarding Children Board, as Alex was under the age of 18 years at the time of his death. I have also sent a copy to the Mansfield and Ashfield CCG and the Department of Health who may find it useful or of interest. I am also under a duty to send the Chief Coroner a copy of the responses received from the organisations listed in section 6 above. 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 2 May 2019 Signature__________ Laurinda Bower, Assistant Coroner, Nottingham City and Nottinghamshire _______________ ##DW<<corAddress>> Tel ##DW<<corTel>> | Fax ##DW<<corFax>>
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.
1 Trevelyan
Square
Boar Lane Leeds
LS1 6AE
0113 397 3614
Leila Blackmore
Coroner’s Office
The Council House
Old Market Square
Nottingham
NG1 2DT
Email correspondence to: leila.blackmore@nottinghamcity.gov.uk
Our reference: LT02134
18th June 2019
Dear Leila
Inquest into the death of Alexander James Davidson
I am writing in response to a Regulation 28 report received from HM Senior Coroner, dated 2nd
May 2019. This follows the death of Alexander James Davidson who sadly passed away on 26th
February 2018. This was followed by an investigation and inquest which concluded on 5th March
2019. NHS Pathways is the clinical decision support software used by all 111 service
providers, and some 999 ambulance service providers including Derbyshire Health
United. I am
, RGN, RSCN, BSc, SPQ and am writing in my capacity as Deputy
Clinical Director, NHS Pathways, NHS Digital.
HM Coroner has raised the following matters of concern with regards to NHS Pathways:
1. The NHS 111 telephone triage service uses the NHS Pathways computer system to triage
patients via pre-determined question/answer-based algorithms. The pre-determined
questions are the same whether the caller is an adult or a child. Alex struggled to
comprehend some of the medical terminology used during these calls. Call handlers are
not permitted to deviate from the prescribed wording of the pre-determined questions, and
this created confusion and inconsistency in the patient’s answers. Consideration should be
given as to how young and/or vulnerable patients can be assisted to provide accurate
information about their symptoms: and
2. The NHS Pathways algorithm for triaging vomiting and diarrhoea symptoms is unclear as
patients may fail to understand what is meant by ‘soil’ or ‘coffee ground’ vomit.
Consideration should be given to how this important diagnostic feature can be explored
during telephone triage, especially when the patient is young and/or vulnerable.
www.digital.nhs.uk
enquiries@nhsdigital.nhs.uk
NHS DIGITAL’S RESPONSE
For information, I have provided below a short summary of the functions that NHS Pathways
performs and the governance that underpins it. I have also attached to this letter a Coroner’s
Information Pack which provides further details and may be useful for your future reference.
Function of NHS Pathways
NHS Pathways is a programme providing the Clinical Decision Support System (CDSS) used
in NHS 111 and half of English ambulance services. This triage system supports the remote
assessment of over 16.5 million calls per annum. These calls are managed by non-clinical
specially trained call handlers who refer the patient into suitable services based on the
patient’s health needs at the time of the call. These call handlers are supported by clinicians
who are able to provide advice and guidance or who can take over the call if the
situation requires it. The system is built around a clinical hierarchy, meaning that life-
threatening problems assessed at the start of the call trigger ambulance responses, progressing
through to less urgent conditions which require a less urgent response (or disposition) in other
settings.
Governance of NHS Pathways
The safety of the clinical triage process endpoints resulting from a 111 or 999 assessment using
NHS Pathways, is overseen by the National Clinical Governance Group, hosted by the Royal
College of General Practitioners. This group is made up of representatives from the relevant
Medical Royal Colleges. Senior clinicians from the Colleges provide independent oversight and
scrutiny of the NHS Pathways clinical content.
Alongside
this independent oversight, NHS Pathways ensures its clinical content and
assessment protocols are consistent with the latest advice from respected bodies that provide
evidence and guidance for medical practice in the UK. In particular, we are consistent with the
latest guidelines from
• NICE (National Institute for Health and Clinical Excellence)
• The UK Resuscitation Council
• The UK Sepsis Trust
To specifically answer the concerns raised:
The NHS 111 telephone triage service uses the NHS Pathways computer system to
triage patients via pre-determined question/answer-based algorithms. The pre-
determined questions are the same whether the caller is an adult or a child. Alex
struggled to comprehend some of the medical terminology used during these calls.
Call handlers are not permitted to deviate from the prescribed wording of the pre-
determined questions, and this created confusion and inconsistency in the patient’s
answers. Consideration should be given as to how young and/or vulnerable patients
can be assisted to provide accurate information about their symptoms:
www.digital.nhs.uk
enquiries@nhsdigital.nhs.uk
NHS Pathways agree that the predetermined questions within the triage algorithms must elicit
accurate information from patients regardless of age and vulnerability. Some questions are the
same for all age groups where the question itself doesn’t need to be age specific, however
there are also many age specific questions throughout the algorithms.
Call handlers are permitted to deviate from the exact wording presented by the system to a
certain extent as each question has supplementary text called ‘supporting information’; the
purpose of which is to guide the call handler to form additional probing questions or alternative
ways of phrasing a question if a patient/caller might not understand what’s being asked.
Call handlers receive communication skills training to equip them with the skills to be able to
adapt their questioning style according to the different needs of different patient groups.
Adapting the approach is an important part of a call handler’s role. However, age is not the only
reason for a lack of comprehension and therefore, irrespective of a patient’s age, call handlers
are trained to avoid jargon and to be alert for signs that a patient/caller hasn’t understood what’s
being asked.
To this end, call handlers receive significant training in questioning and listening skills during
initial core training and through ongoing training updates. This is supported and monitored
through monthly call audit. This training and on-going monthly call audit are all mapped to the
NHS Pathways Competencies. An excerpt of the relevant competency (competency 3.1) in
relation to ‘listening’ is shown below:
‘3.1 Listens carefully throughout the call and retains this information
This means picking up everything that the caller says. It also means picking up on everything
else that is communicated by the caller, aside from the actual words they use. This includes
the caller’s demeanour, for example do they sound breathless, confused, disorientated, in pain,
weak etc. It also means picking up on things like speech patterns and pauses or vague
responses. It means picking up feelings such as fear, frustration, anger and anxiety.’
Although call handlers are permitted to re-word questions, it is important that they don’t change
the clinical essence of what’s being asked. The supporting information provides additional
guidance about the clinical intention of a question and the different ways this might be
described. An excerpt from the relevant competency (competency 2.1) which guides training
and audit in this area, is shown here:
‘2.1 Conveys questions skilfully
Whilst retaining the clinical meaning, it is essential to phrases questions in a way that callers
can understand. It would be entirely possible to convey the clinical meaning of a question
accurately but have a situation where the caller does not understand what is being asked,
which clearly renders the question useless. Therefore, skill is needed in phrasing questions so
that they are easily understood. This means that the call handler needs to be adaptable
according to the needs of the situation and should use the supporting information to guide them
in forming alternative ways of asking the same question.
Jargon should be avoided. Jargon is terminology that relates to a specific activity, profession
or group. In the context of telephone triage, it means avoiding the use of medical jargon or
terminology which is service or system specific.’
Furthermore, call handlers receive significant training in telephone-based communication skills,
as well as monthly audit against communication focused competencies. An excerpt of the
relevant competency (5.3) is shown here:
www.digital.nhs.uk
enquiries@nhsdigital.nhs.uk
‘5.3 Adapts approach according to the needs of the situation
This means recognising when the situation demands a different type of communication and
changing the approach accordingly. For example, if a person is hard of hearing it may be
necessary to speak more slowly, use shorter sentences or increase the volume. It may also
involve utilising translation services where required.’
In addition to the competencies and skills training listed above, which if met should allow a call
handler to communicate successfully with the majority of callers of all ages and vulnerabilities,
there is an option to Early Exit triage and transfer to a clinician to provide assistance to
vulnerable adults and children.
The following are examples of when triage exit routes are used to transfer calls to a clinician:
• The contact is a child and unable to answer questions.
• There is difficulty obtaining adequate information (e.g. a caller who seems very vague or
unable to focus on the questions being asked or a caller who is incoherent or extremely
difficult to communicate with).
• The caller has difficulty deciding which symptom is troubling them the most.
• A diagnosed condition or medical language complicates the situation.
The NHS Pathways algorithm for triaging vomiting and diarrhoea symptoms is unclear
as patients may fail to understand what is meant by ‘soil’ or ‘coffee ground’ vomit.
Consideration should be given to how this important diagnostic feature can be
explored during telephone triage, especially when the patient is young and/or
vulnerable.
The question (see example below) currently asks whether there has been ‘dark brown or black
vomit, like coffee-grounds’.
Supporting information is available to assist call handlers when extra probing or rephrasing of
the question is required. The supporting text states ‘This means the individual has brought up
or vomited dark brown or black material that looks like soil or coffee-grounds. Blood that has
been in the stomach often looks like this’.
www.digital.nhs.uk
enquiries@nhsdigital.nhs.uk
In 2018 NHS Pathways reviewed the question that asks about dark brown or black vomit in
view of the concern that callers may not be familiar with the term ‘coffee-grounds’. Removing
the 'coffee-grounds' description could result in over referral as dark/black fluid alone without
texture ('bits') could be drinks (e.g. cola, coffee, Guinness) or other dietary intake that has been
vomited. The reference to coffee-grounds is a texture that is reasonably specific to
haematemesis and this is commonly used in health-related literature, whereas cola is not.
NHS.uk also refer to coffee-ground appearance only.
In 2016 NHS Pathways added reference to ‘soil’ in the ‘supporting information’ of the question
asking about vomiting blood.
NHS Pathways are, as part of routine review and governance procedures, conducting a review
of the gastrointestinal suite of pathways (including the diarrhoea and vomiting pathways), with
changes planned for Release 19 (which will be deployed May 2020). As part of this review, the
clinical evidence related to haematemesis will be reviewed with consideration also given as to
whether user research will be helpful in improving triage questions and the identification of
haematemesis.
I am happy to answer any further enquiries from HM Coroner.
Yours sincerely
Deputy Clinical Director
NHS Pathways
www.digital.nhs.uk
enquiries@nhsdigital.nhs.uk
N | C National Institute for 10 Spring Gardens Health and Care Excellence London SW1A 2BU United Kingdom +44 (0)300 323 0140 18 June 2019 Laurinda Bower HM Assistant Coroner Nottingham & Nottinghamshire Coroner's Service Nottingham City Council Human Resources and Transformation Directorate The Council House Old Market Square Nottingham NG1 2DT Our ref:EH103945 Dear Ms Bower, Thank you for your letter of 8 May concerning the death of Alexander James Davidson. You suggest that consideration should be given to a national approach for lipase/amylase testing in young people with relevant symptoms, and to the arrangements for reviewing paediatric patients who make an unscheduled return to an Accident and Emergency Department within 72 hours of discharge. Our guideline on pancreatitis (NG 104). notes (in section 1.2) that “Diagnosis of acute pancreatitis is confirmed by testing blood lipase or amylase levels, which are usually raised. If raised levels are not found, abdominal CT may confirm pancreatic inflammation’. However, because the purpose of the guideline is to recommend treatments following diagnosis of acute pancreatitis, the accuracy of lipase or amylase in young people is not considered in it. Nevertheless, in the light of your letter, we'll reconsider the scope of the guideline when it is next reviewed. NHS England and NHS Improvement, rather than NICE are jointly responsible for helping NHS providers to achieve the right levels and mix of staff, including in Accident and Emergency Departments. rc Yours sincerely, Andrew Dillon Chief Executive www.nice.org.uk | nice@nice.org.uk
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