Prevention of Future Deaths reports · 2020
Regulation 28 report to prevent future deaths, reference 2020-0147, written 31 Jul 2020. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 31 Jul 2020 |
|---|---|
| Reference | 2020-0147 |
| Deceased | Amy Hogan |
| Coroner | Christopher Morris |
| Coroner area | Manchester South |
| Category | Alcohol, drug and medication related deaths · Community health care |
| 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 Right Hon. Matt Hancock MP, Secretary of State for Health and Social Care; Sir Simon Stevens, Chief Executive, NHS England. 1 CORONER I am Chris Morris, Area Coroner for Greater Manchester South. 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. http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made 3 INVESTIGATION and INQUEST - On 1 Slh April 2020, Alison Mutch OBE, Senior Coroner for Greater Manchester South, opened an inquest into the death of Amy Hogan who died at Tameside General Hospital, Ashton under Lyne on 21 st January 2020, aged 23 years. The Investigation concluded at the end of the inquest, which I heard on 2nd July 2020. A post mortem examination determined Miss Hogan died as a consequence of:- 1 )a) Hypoxic !brain injury; b) Pulmonary embolism; c) Deep vein thrombosis II Oral contraceptive pill, obesity. I The inquest concluded with a narrative conclusion to the effect that Miss Hogan died as a consequence of complications of a deep vein thrombosis. Whilst this Is a natural cause of death, it is likely her death was contributed to by a recognised complication of the oral contraceptive pill. 4 CIRCUMSTANCES OF THE DEATH I I From around September 2019, Miss Hogan began to report sporadic and non-specific symptoms of feeling unwell. Having initially attended the Pennine Medical Centre in Mossley as a visiting patient, Miss Hogan registered with that oractice. Miss Hoaan received treatment from doctors at the practice for depression and anxiety, and continued to be prescribed the oral contraceptive pill following a risk assessment by the practice pharmacist. On 2011h January 2020, Miss Hogan attended the out of hours doctor at Oldham Primary Care hub, reporting a 3 day history of feeling light- headed, weak and drained. Whilst Miss Hogan had told others she had experienced breathlessness and leg pain,'this information was not conveyed to the out of hours doctor. Whilst Miss Hogan disclosed to the doctor details of the anti-depressant medication she had been prescribed, he was not informed she was taking the oral contraceptive pill. I I I I The following day, Miss Hogan became acutely unwell and collapsed at her home. She was taken to hospital by ambulance where she died. 5 CORONER'S CONCERNS During the course of the inquest the evidence revealed matters giving rise 1 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 inquest heard evidence from Miss Hogan's regular GP that, despite being requested, the General Practice records from her previous practice never arrived. It is a matter of concern that delayed, incomplete or non-existent transfer of patient data from one practice to another on moving places an unfair burden on patients to accurately recall and relay their own medical histories. It is a matter of particular concern that such issues create particular problems for vulnerable patients, who simply may not be in a position to do so; 2) Notwithstanding numerous previous initiatives as to information-sharing and digitisation of patient data, it is a matter of concern that the out of hours GP reviewing Miss Hogan had no electronic access to her regular GP records. Access to such records would have revealed, amongst other things, Miss Hogan was prescribed the oral contraceptive pill, which is likely to have led the doctor to ask additional questions about her symptoms. Again, it is a matter of particular concern that an inability to access regular GP records in the out of hours setting raises additional risks for vulnerable patients. 6 ACTION SHOULD BE TAKEN I In my opinion action should be taken to prevent future deaths and I believe you 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 25th September 2020. 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 and to Miss Hogan's parents. I have also sent a copy of my report to Dr- and Dr • who may find it useful or of Interest. I have also sent it to Tameside CCG. 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 Chri~topher Morri HM ~rea Coroner, Manchester South 31.07.2020
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.
National Medical Director NHS England & NHS Improvement Skipton House 80 London Road London SE1 6LH 29th October 2020 Mr Christopher Morris Coroner’s Court, 1 Mount Tabor Street, Stockport SK1 3AG Dear Mr Morris, Re: Regulation 28 Report to Prevent Future Deaths – Miss Amy Hogan 21st January 2020 Thank you for your Regulation 28 Report dated 31st July 2020 concerning the death of Miss Amy Hogan on 21st January 2020. Firstly, I would like to express my deep condolences to Miss Hogan’s family. The regulation 28 report concludes Miss Hogan’s death was a result of: 1) a) Hypoxic brain injury b) Pulmonary embolism c) Deep vein thrombosis 2) Oral contraceptive pill, obesity Following the inquest, you raised concerns in your Regulation 28 Report to NHS England relating to the transferring of GP records following registration at a new practice, and access to GP records in an out of hours setting. This response has been made with input from NHSX, the organisation responsible for NHS technology, digital and data - including data-sharing and transparency. Over recent months significant progress has been made around the access to GP records out of hours. As a response to the pandemic, we have enabled the use of GP-Connect across the whole primary care estate. This eases facilitation for authorised professionals in multiple care settings to directly access in a safe and secure manner GP records which are held at GP out of hours services, CCAS, Extended Access Hubs and NHS 111. We have also enabled wider access by authorised professionals to an enriched Summary Care Record with Additional Information (SCR-AI), which allow a health and care professional to see a patient’s medical history and helps to support older patients and those with complex comorbidities. Over 54 million patient records (90%) of the population in England, now include enriched summary care records. We are working with GP system suppliers and NHS England and NHS Improvement continue to make progress. We are looking at ways to ensure that these changes can be retained for the future given the impact it has had for faster and better care. There is an ongoing programme of work to review and establish and reduce the root cause of electronic GP2GP (GP2GP is the formal term for the programme) record transfer failures. In March 2020 there was an increase applied by GP system suppliers to GP2GP transfer ‘file size’ from 50MB to 100MB, this will subsequently help to reduce the rate of failures further. Due to COVID-19 competing priorities, statistics are not yet available to demonstrate the effect this change has had. However, we anticipate analysis and collection of these metrics will resume as part of the recovery work. We continue to make progress on the digitisation of GP records, including the programme to digitise historic information held in the Lloyd George paper medical records. There are 4 main reasons for digitisation of Lloyd George records: - safer care for patients, - release of space within practices to provide additional consultation areas, - access to the full patient record at the point of care, - GP contract commitment to digitise all Lloyd George records by March 2022. Lloyd George Paper Records Digitisation Project: Wave 1 Pilot sites: • Sunderland - Digitised 17 of 38 practices with 132k patient paper records digitisation complete. On completion Sunderland will have digitised 284k patients paper records. • Lancashire ICP (Morecambe Bay CCG) – Digitisation underway, on completion 350k patients paper records digitised across the CCG • Birmingham & Solihull CCG – Digitisation underway, on completion 1.3m patients paper records digitised. In total – on completion Wave 1 pilots will have digitised 1.9m patient paper records. Wave 2 Pilots (Procurement Phase – work is underway and due to be completed by March 2022. digitisation of Lloyd George records is March 2022 Participation across all 7 regions o North West – 1.9m o North East & Yorkshire – 804k o Midlands – 1.3m o East of England – 982k o London – 1.4m o South East – 1.6m o South West – 1.1m In total – on completion Wave 2 have plans approved to digitise 9m patients paper records to be digitised. We sincerely hope that this provides reassurance that progress is being made around the digitisation and transfer of medical records, in order to prevent such tragic events reoccurring in the future. Thank you for bringing these important issues to my attention and please do not hesitate to contact me should you need any further information. Yours sincerely, Professor Stephen Powis National Medical Director
See every Prevention of Future Deaths report matching Alcohol, drug and medication 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.