Prevention of Future Deaths reports · 2020
Regulation 28 report to prevent future deaths, reference 2020-0291, written 24 Sep 2020. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 24 Sep 2020 |
|---|---|
| Reference | 2020-0291 |
| Deceased | Eileen Brindley |
| Coroner | Joanne Lees |
| Coroner area | Black Country |
| Category | Community health care · Other related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
1 2 3 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Tettenhall Medical Practice; CORONER I am Mrs Joanne Lees, Area Coroner, The Black Country Jurisdiction 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. INVESTIGATION and INQUEST On 15/9/20 I conducted an inquest touching the death of the late Eileen Brindley who died on the 28th August 2020 at New Cross Hospital, Wolverhampton, West Midlands. Having considered all the available evidence, I, the Coroner made the following findings of fact; ‘On 28/8/20 the deceased a frail 97-year-old lady was admitted to hospital having been found by her carer struggling to breath. She was believed to have suffered a severe allergic reaction and sadly passed away in hospital shortly afterwards. She was known to be allergic to Flucloxacillin and had recently been prescribed a penicillin type antibiotic for and throat/ear infection’. The Medical Cause of Death was: 1a) Anaphylaxis The inquest concluded with a short form conclusion of accidental death 4 CIRCUMSTANCES OF THE DEATH i) ii) iii) iv) v) vi) On the evening of 28/8/20 the deceased was admitted to New Cross Hospital having been found at home by her carer struggling to breathe; On arrival of the emergency services she was she was noted to be in severe respiratory distress with a GCS of 6; On arrival in the ED at approximately 10 pm she was noted to have a gcs 3/15, breathing laboured, Sats on air 69%, wide spread urticarial rash to chest and back; She was treated with back to back nebulisers, iv hydrocortisone, iv Chlorphenamine, magnesium and iv fluids with no improvement; Her breathing worsened, and she was confirmed as deceased at approximately 10.32 pm; Paramedic’s reported on arrival at the address a box of Flucloxacillin was found by the deceased and stated some had been taken and that the deceased had previously suffered a severe vii) viii) ix) x) adverse reaction to Flucloxacillin which was documented in her previous hospital attendances; Information provided by the Medical Examiner was that the cause of death on a balance of probability was 1a) Anaphylaxis, and that the deceased Mrs Brindley was found to be allergic to Fluclox during an admission in April 2020, and this was highlighted on her discharge summary; A print out from the deceased GP Practice Tettenhall Medical Practice revealed an entry dated 3/7/20 under the heading Allergies ‘Adverse reaction to Flucloxacillin’; The same print out revealed a telephone prescription was made for Amoxicillin on 21/8/20 for a throat/ear infection; The Medical Examiner at New Cross Hospital concluded the deceased had died from an allergic reaction irrespective of whether the drug found was Flucloxacillin or Amoxicillin and that any penicillin should not have been prescribed. 5 CORONER’S CONCERNS During 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) That a prescription was issued for a penicillin type antibiotic on 21/8/20 despite an entry in the medical records of the deceased highlighting a previous adverse reaction to Flucloxacillin; 2) There was no evidence that the prescribing clinician had noted the adverse reaction entry and/or there was no explanation why the medication had been prescribed even if that entry had been noted; 3) The prescription was issued with any consultation either in person or over the telephone; 4) That entries into medical records are not sufficiently highlighted to any clinician who is unfamiliar with the previous medical history of the deceased; 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you and/or your organisation have the power to take such action. Tettenhall Medical Practice may wish to review how allergies are recorded within electronic patient records. The GMC may wish to review the actions of the prescribing Doctor and consider whether any further action is necessary. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 20/11/20. 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 the following Interested Persons , son of the deceased. I have also sent a copy of my report to the GMC. 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 Mrs Joanne M. Lees Area Coroner The Black Country Jurisdiction 24/9/20
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.
THE TETTENHALL MEDICAL PRACTICE TETTENHALL MEDICAL PRACTICE LOWER STREET TETTENHALL WOLVERHAMPTON WV6 9LL WV6 8NF TETTENHALL MEDICAL PRACTICE WOOD ROAD TETTENHALL WOOD WOLVERHAMPTON Telephones: 01902 444550/444551 Telephones: 01902 444560/444561 Mrs Joanne Lees Area Coroner The Black Country Jurisdiction Coroner’s Court Jack Judge House Halesowen Street Oldbury B69 2AJ Sent By Email Only: 18 December 2020 Dear Mrs Lees I write on behalf of the Tettenhall Medical Practice in response to your Regulation 28 Report dated 24 September 2020. We note the concerns you have raised and write to reassure you of the steps that the Practice have taken to implement change and review how allergies are recorded within the electronic patient records. Practice Discussions 1) On the 6 October 2020 the practice held a significant event analysis. All partners, managers and nurses were present and the details of Mrs Brindley’s care were presented and learning outcomes discussed at length. 2) A practice meeting was then held on 7 October with all non-clinical staff present. The conclusions of the SEA were disseminated to ensure that we all learn from the sad outcome in this case and implement changes to ensure there is no risk of repetition. 3) A further practice meeting was held on 8 December 2020 to discuss the two new policies being implemented (more set out at numbered paragraphs 4 and 5 below) and an update was provided regarding developments with a response to HM Coroner and to NHSE. Practice Changes 4) We have reviewed how allergies are recorded in the medical records. Our discussions focused on the issues generated by this case but included a broader review of coding of all allergies. Following those discussions we have updated our policy ‘Recording Allergies in Patient Records’ and this has been provided to all staff in hard copy and is accessible on a shared computer drive. The key points are: a) There should be a consistent approach. b) The records should clearly state within the ‘active problems’ section if the patient has any allergy so as to ensure this information is apparent and easily accessible to anyone reviewing the records, particularly any clinician who may be unfamiliar with the previous medical history. c) The severity of any reaction must now be recorded i.e. mild, moderate or severe. We felt that this approach would help to differentiate between mild and severe allergic the particular circumstances. reactions, encouraging clinicians to appreciate d) The code should now also include a description of the reaction such as rash, swelling or chest tightness. Again, this is to assist clinicians to appreciate the particular circumstances. e) We identified that the date of the allergic reaction generating the alert code does not show up when renewing a previous prescription. This issue has been highlighted and EMIS has been asked to look into the possibility of introducing this function in the alert system. Enabling this facility would allow a clinician to be better informed about the date of the previous allergic reaction before issuing a prescription. 5) We have also updated our policy on remote consultations. Previously the policy indicated that if a request is made to return a patient’s telephone call then a call should be made and, if there is no response, a voicemail left but it was then up to the patient / carer to return that call. The salient change is that the clinician or administrative staff must now call the patient back and, if there is no reply, leave a voicemail and make a second call at least half an hour apart from the first attempt. 6) The practice is carrying out an extensive audit of all allergic reactions recorded on the electronic record system. This audit is being conducted by one of the administration team with oversight from the Practice Manager. All allergies and side effects are recorded as an ‘adverse reaction’ as this is the only alert code available. However this audit is conducting a review to make sure that wherever possible additional notes are made giving a wider description including, where known, whether the reaction is allergy/side effect, new/historical, mild/severe and symptoms of the reaction such as a rash or breathing difficulties. 7) It is now mandatory to ensure a face to face or remote consultation has taken place before prescribing any medication, ideally with the patient themselves but where this is not possible then with their carer or another healthcare professional involved in their care. 8) All clinicians have been reminded to specifically check allergies documented in the clinical record summary before prescribing for any patient. 9) Clinicians have been instructed never to prescribe any medication which has an electronic alert indicating the patient has an allergy. 10) All clinicians and administrative staff have been instructed to accurately code any prescription alerts. Wider Education 11) has completed various educational updates including a MIMS course on avoiding prescription errors, RCGP course on prescribing, MDU course on remote consultation skills, MIMS course on allergy and anaphylaxis and BMJ course on tips for coping with change during a pandemic. 12) All clinicians have refreshed their knowledge that allergies can develop at any age and patients can suffer with anaphylaxis from drugs to which they are allergic. 13) Reminder has been made to all clinicians always to make clear and detailed notes in the patient records. 14) has reviewed various medical journal articles around the subjects of penicillin allergies and anaphylaxis from penicillin. We hope that this will reassure HM Coroner that the Tettenhall Medical Practice have very much taken her concerns on board and have taken steps to review our processes and implement change. Yours sincerely On behalf of The Tettenhall Medical Practice
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