Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0210, written 21 Jun 2021. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 21 Jun 2021 |
|---|---|
| Reference | 2021-0210 |
| Deceased | Judith Varley |
| Coroner | Mary Burke |
| Coroner area | West Yorkshire Western Division |
| Category | Community health care |
| 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.
IN THE WEST YORKSHIRE (WESTERN) CORONER’S COURT IN THE MATTER OF: The Inquest Touching the Death of Judith VARLEY A Regulation Report — Action to Prevent Future Deaths REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: 1 Managing Partner ~— Wilsden Medical Practice 1 CORONER | am Mary Burke, Assistant Coroner for the area of West Yorkshire Western Division jurisdiction 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 Date investigation opened 11th December 2019. Date inquest concluded 21 April 2021. Conclusion Narrative -On 24 December 2019 Judith Varley underwent right hip replacement surgery at The Yorkshire Clinic Bingley West Yorkshire. During the course of the operation she suffered sudden catastrophic bleeding which despite all appropriate medical and surgicai efforts resulted in her death during the procedure. It is likely that the bleeding was from a tear to the femoral vein which occurred when her treating surgeon undertook a necessary manipuiation of her hip joint during the operation. 4 CIRCUMSTANCES OF THE DEATH In March 2009 Mrs Varley suffered an accident sustaining extensive burns to the left side of her body, despite hospital treatment she developed complications leading to an above knee left leg amputation. During this time she was also diagnosed with peripheral vascular disease and underwent a right sided ileo-femoral bypass graft to improve the blood supply to her right leg. In 2013 she underwent further vascular procedures namely an angioplasty and patch repair at the sight of her previous by-pass graft. In 2019 she developed right hip pain, she consulted your practice and was referred by letter to Mr Thomas consultant orthopaedic surgeon, who recommended right hip replacement surgery. During the course of surgery undertaken at The Yorkshire Clinic Bingley on 2"! December 2019, Mrs Varley suffered a catastrophic bleed, which despite both medical and surgical intervention led to her death in the operating theatre a short time later. During the course of the inquest, it was established that the coding given and entered on the computer system of the Wilsden Practice for Mrs Varley’s Surgery in 2013 was not in fact an accurate description of the surgery which she had undergone at that time. This led to an inaccurate description of this surgery within the referral letter submitted by Wilsden Practice at the time of Mrs Varley referral in 2019 for her right hip pain. In the inquest evidence RM from the practice. 1. she was unable to clarify if there was in fact an alternative coding in 2013 which would have accurately reflected the surgery performed. 2. She was not familiar with the system to know if the coding can be overrided so as to ensure an accurate description of a procedure can be recorded, when the coding options available do not provide an accurate description 3. As she is not the designated doctor within the practice, she was not aware of what auditing / reviewing systems operated within the practice so.as to ensure the accurate inputting of information into the practices computer system | would wish to stress that there was no evidence at the inquest which indicated that this issue in any way caused or contributed to Mrs Varley's death. However i consider that this issue does potentially pose a risk which could impact on the lives of others, hence the reason for reporting this matter to you. 5 CORONER’S CONCERNS The MATTERS OF CONCERNS are as follows: (brief summary of matters of concern) 1. The computer coding entered by the practice in respect of Mrs Varley’s 2013 procedures did not accurately describe the procedure undertaken. 2. It was unclear whether the operating coding computer system in 2013 had facility to be overrided to ensure an accurate description was entered on the system. 3. It was unclear if there was /is an auditing / quality control system in place in the practice to ensure accurate inputting of information within the coding process. 6 ACTION SHOULD BE TAKEN 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 16 August 2021. 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 | have sent a copy of my report to the Chief Coroner and to the following Interested Persons 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, eponer UF ¢ CHO wn Dated: we a “2. i ‘
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.
Wilsden Medical Practice Inquest Touching the Death of Judith Varley Regulation 28 Report Action to Prevent Future Deaths 05 August 2021 Introduction This report reviews the coding of medical records in relation to the death of Mrs Judith Varley. We acknowledge an incorrect clinical code was recorded in the patient record for Mrs Varley and recognise the distress this will have caused her family. We also recognise the importance of ensuring the accuracy of clinical coding and to support continual learning. We have undertaken a review our process using best practice guidance and discussed this with our data and clinical teams. The following matters of concern were noted in the Regulation 28 report in the inquest touching the death of Mrs Judith Varley: 1. The computer coding entered by the practice in respect of Mrs Varley’s 2013 procedures did not accurately describe the procedure undertaken 2. 3. It was unclear whether the operating coding computer system in 2013 had the facility to be overrided to ensure an accurate description was entered on the system. It was unclear if there was/is an auditing/quality control system in place in the practice to ensure accurate inputting of the information within the coding process. Matter 1 - Coding used in 2013 “The computer coding entered by the practice in respect of Mrs Varley’s 2013 procedures did not accurately describe the procedure undertaken.” The NHS used the CTV2 coding system in 2013. The coding system has been updated several times since 2013 and the current version is called “SNOMED CT”. It is common for the same naming to carry over between updates but we have not been able to verify if the current codes are exactly as they were in 2013. The code record in the patient record in 2013 was: • Patch angioplasty of renal artery (XaLhR) (SNOMED: 426736009) This code refers to the renal artery whereas the discharge letter refers to “ilio-femeral bypass stenosis”. We acknowledge that the code in the patient record did not accurately describe the procedure undertaken. With regard to preventing future deaths, we can assure the coroner that the current coding system does include codes that identify the site of the patch. Using the current system we could apply two codes, one for the angioplasty and one for the patch repair: Page 1 of 4 Wilden Medical Practice Inquest Touching the Death of Judith Varley Regulation 28 Report Action to Prevent Future Deaths • Prosthetic graft patch angioplasty (XaDyk) (SNOMED: 312610006) – we would also add free text to the code to state “ilio-femoral bypass stenosis”. This is discussed in the next section. • Patch repair femoral artery (XaCLV) (SNOMED: 310621009) Matter 2 - Overriding or changing codes “It was unclear whether the operating coding computer system in 2013 had the facility to be overrided to ensure an accurate description was entered on the system.” The current methods for correct codes is the same as it was in 2013, namely: • • Incorrect entries in patient records (including codes, letters, consultation notes etc) can be given the status of “marked in error”, i.e. the entry is not deleted. This removes that entry from the visible record while also ensuring the error can be checked or reinstated. It is also possible to respectively add entries (including codes, letters, consultation notes etc). These appear in the record on the retrospective date, but please note that it is also possible to identify when that entry was added. For example we receive discharge letters for operations several days after the operation and we record the code for operation using the date the operation took place. • Free text can be added to a code for clarity. This is often used to identify the site of a procedure or diagnosis. Examples include the location for a skin condition, or the left/right side of the body for arms, eyes, kidney etc. The combination of the above methods means that incorrect codes can be corrected and free text can be used to add further detail to improve accuracy. Matter 3 – Quality Control It was unclear if there was/is an auditing/quality control system in place in the practice to ensure accurate inputting of the information within the coding process. Process Our processes for coding incoming communications has changed considerably since 2013. We have highlighted below where our current process differs from the system used in 2013. We reviewed our coding process against practice policy. The process is: 1. Discharge forms are normally computer generated and imported into our clinical system by our team. This is a fully digital process whereas all our hospital communications in 2013 were paper based. For example Mrs Varley’s discharge summary in 2013 was a handwritten form received in the post. Note we do still receive some communications in the post but the number is low and we digitise those items on arrival. 2. Our Data Quality team review each communication (such as clinical letters, reports or discharge summaries), check it is in the correct patient record and apply appropriate clinical Page 2 of 4 Wilden Medical Practice Inquest Touching the Death of Judith Varley Regulation 28 Report Action to Prevent Future Deaths coding. They also highlight on screen what they have coded and can add questions or comments in free text. The item is then assigned to a GP for review. In 2013 the data team would need to flit between the paper original and onscreen display. 3. The reviewing GP then reads the letter within the patient record. This automatically displays the applied codes on screen alongside the letter and any comments from the data team. The GP changes the status of the letter to “complete” once they have reviewed the letter, codes and associated tasks (for example a meditation change). This process includes the following checks: • The coder checks the communication is attached the correct patient record. • The GP checks the correct coding has been used. • There is a feedback/learning loop when the GP returns items to the data team for correction. The current process has become significantly more robust than in 2013: • Discharge information is computer generated from the hospital record so we’re not relying on handwritten notes. • Coding is directly linked to the letter on screen and it is easy to look up the correct code with • the letter on screen. Items follow a fully digital process so there is much less risk of information being lost or overlooked. • The fully digital process removes problems with handling a lot of paper, for example pages stuck together when scanned. • Also, please note that now that the hospital uses digital process for generating letters it is easier to enquire about details on discharge letters because they no longer need to retrieve paper records from their archive. This makes it much easier to verify that the information we have been given is correct. Audit We undertook the following audit in July 2021 to review the coding process for incoming documents. We plan to repeat this in 3 months including a review of the scale, scope and frequency. A summary of the audit is below: Aim: • To review accuracy of coding and tasks associated with incoming clinical letters Method: • The letters were reviewed by a GP. Sample: • A random sample of 50 clinical letters were selected. Page 3 of 4 Wilden Medical Practice Inquest Touching the Death of Judith Varley Regulation 28 Report Action to Prevent Future Deaths Findings: Number of letters Sample 50 Correct 49 (95%) Incorrect 1 (5%) • The incorrect letter had omitted a code that that a CT scan had been undertaken. The clinical aspects of the letter were correctly coded & actioned. Outcome: • No items of significant concern were noted. • Findings have been discussed with clinical team and data team • This is a new audit process for the practice so we plan to repeat the audit cycle in 3 months. This is to include a review of the scale, scope and frequency required to ensure continued accuracy of coding clinical information. Page 4 of 4
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