Source · Prevention of Future Deaths

Fadzai Chitakunye

Ref: 2022-0261 Date: 31 Mar 2022 Coroner: Dianne Hocking Area: Leicester City and South Leicestershire Responses identified: 1 / 1 View PDF

Significant delays in transferring patient notes between GPs risk important medical history being missed, especially for patients unable to effectively communicate their past health information.

Date 31 Mar 2022
56-day deadline 28 Nov 2022 est.
Responses identified 1 of 1
Other related deaths

Coroner's concerns

AI summary
Significant delays in transferring patient notes between GPs risk important medical history being missed, especially for patients unable to effectively communicate their past health information.
View full coroner's concerns
In this case the transfer of the notes from the deceased’s Nottingham general practitioner to the Leicestershire general practitioner took 11 months as reported to me by the GP. She also reports that notes still take about 16 weeks to be transferred between GP’s. Important information about the patient’s medical history may be missed particularly if the patient is not able to communicate effectively with the new GP.

Responses

1 respondent
Department of Health and Social Care Central Government
10 Jan 2023 PDF
Noted

The Department of Health and Social Care outlines existing NHS services and policies related to electronic health record transfer and access. (AI summary)

View full response
Dear Mrs Hocking,

Thank you for your letter of 31 March 2022 about the death of Fadzai Chitakunye. I am replying as Minister with responsibility for Primary Care and Public Health, and I am grateful for the additional time in which to do so. I wish to begin by saying how saddened I was to read of the circumstances of Mrs Chitakunye’s death and I offer my sincere condolences to her family and loved ones. The circumstances your report describes are very concerning and I am grateful to you for bringing these matters to my attention. General practice is the cornerstone of our NHS and Government is committed to helping staff deliver for patients. The 2016 General Practice Forward View 1 strategy provided support for practices to build the capacity and capabilities required to meet patients’ needs. As part of the GP Forward View, a key aspect included investment in technology to improve patient care and work to increase the electronic transfer of records between practices.

The NHS Long Term Plan2, published in 2019, sets out further ambitions for general practice and builds on the GP Forward View. The Plan includes digital transformation programmes and technology opportunities to improve and support NHS care, including better access by clinicians to electronic/digital health records.

You may wish to note that the General Medical Services (GMS) GP Contract requires practices to use GP2GP for transferring electronic health records. NHS Digital provides the GP2GP service, which allows patients' electronic health records to be transferred directly, securely and quickly between their old and new practices, when they change practices. The GP2GP process is an automated ‘pull’ and transfer of the patient’s digital medical record that is activated when a patient is registered on their new general practice medical system

1 https://www.england.nhs.uk/wp-content/uploads/2016/04/gpfv.pdf 2 https://www.longtermplan.nhs.uk/wp-content/uploads/2019/08/nhs-long-term-plan-version-1.2.pdf

a n d t h er e h a s b e e n a s u c c e s sf ul m at c h t o t h e n ati o n al P er s o n al D e m o gr a p hi c s S er vi c e d at a b a s e. P ati e nt s e x p e ct g e n er al pr a cti c e s t o h a v e t h eir m e di c al r e c or d s a n d t h e G P 2 G P s y st e m h el p s p ati e nt s’ h e alt h r e c or d s t o arri v e s o o n aft er a n e w p ati e nt pr a cti c e r e gi str ati o n. N H S Di git al m a n a g e a n d m ai nt ai n t h e G P 2 G P s er vi c e a n d c o nti n u e t o i m pr o v e a n d d e v el o p t h e s y st e m.

Y o u m a y al s o wi s h t o n ot e t h at Pri m ar y C ar e S u p p ort E n gl a n d ( P C S E) pr o vi d e s a d mi ni str ati v e a n d s u p p ort s er vi c e s f or N H S pri m ar y c ar e o n b e h alf of N H S E n gl a n d, a n d i s r e s p o n si bl e f or t h e m o v e m e nt of p a p er m e di c al r e c or d s. It c a n t a k e u p t o t w o w e e k s f or a n e w pr a cti c e t o r e c ei v e a p ati e nt’ s p h y si c al m e di c al r e c or d. P C S E m a n a g e a s e c ur e d eli v er y s er vi c e t o e n a bl e t h e m e di c al r e c or d t o b e m o v e d c orr e ctl y, a tr a c ki n g l a b el i s a ut o m ati c all y g e n er at e d a n d s e nt t o t h e ol d pr a cti c e a n d d eli v er y arr a n g e d. P C S E h a v e a n o nli n e tr a c ki n g s y st e m t o all o w pr a cti c e s t o tr a c k t h e st at u s of i n b o u n d r e c or d s, vi e w a li st of o ut b o u n d r e c or d r e q u e st s a n d s e e w h at r e c or d s n e e d t o b e pr e p ar e d f or tr a n sf er. T h e l e n gt h of ti m e it t a k e s f or a p ati e nt s’ r e c or d s t o g et t o t h eir n e w pr a cti c e i s m ai nl y d e p e n d e nt o n h o w q ui c kl y t h e ol d pr a cti c e r el e a s e s t h e p h y si c al r e c or d.

Fi n all y, N H S Di git al al s o pr o vi d e t h e S u m m ar y C ar e R e c or d s ( S C R) s er vi c e. S C R s pr o vi d e a n alt er n ati v e o pti o n if h e alt h c ar e pr of e s si o n al s ar e u n a bl e t o a c c e s s a p ati e nt’ s f ull G P cli ni c al s y st e m r e c or d. S C R s ar e a n el e ctr o ni c r e c or d of i m p ort a nt p ati e nt i n f or m ati o n, cr e at e d fr o m g e n er al pr a cti c e cli ni c al s y st e m m e di c al r e c or d, a n d t h e y c a n b e vi e w e d a n d a c c e s s e d b y a ut h ori s e d h e alt h c ar e pr of e s si o n al s i n v ol v e d i n a p ati e nt’ s dir e ct c ar e fr o m l o c al r e gi o n al a n d n ati o n al h e alt h c ar e s y st e m a n y w h er e i n E n gl a n d. T h e S C R i n cl u d e s t h e f oll o wi n g i nf or m ati o n: c urr e nt m e di c ati o n, all er gi e s, pr e vi o u s b a d r e a cti o n s t o m e di ci n e s, n a m e, a d dr e s s, d at e of birt h a n d N H S n u m b er, a n d m a y al s o i n cl u d e, si g nifi c a nt m e di c al hi st or y, r e a s o n f or m e di c ati o n, a nti ci p at or y c ar e i nf or m ati o n, e n d of lif e c ar e i nf or m ati o n, i m m u ni s ati o n s.

I h o p e t hi s r e s p o n s e i s h el pf ul.

N EI L O’ B RI E N M P

Report sections

Investigation and inquest
On 01 March 2019 I commenced an investigation into the death of Fadzai CHITAKUNYE aged 45. The investigation concluded at the end of the inquest on 29 March 2022. The conclusion of the inquest was Natural Causes due to 1a) Haemorrhage into high grade astroglial brain tumour
2) Progression of hepatitis B infection following chemotherapy
Circumstances of the death
Fadzai Chitakunye was diagnosed with a brain tumour in 2010. Her compliance with the advised treatment was not always consistent. She had been diagnosed with hepatitis B in 2004 in Nottingham but this information had not been passed onto her general practitioner until 2010. She was not referred to a hepatologist and the oncologist treating her was unaware of her hepatitis B infection. If she had been, it is likely that Mrs Chitakunye would have been given anti-virals whilst having the chemotherapy treatment which might have improved her liver disease. Mrs Chitakunye died from a haemorrhage into her brain tumour on the 26 February 2019 at Leicester Royal Infirmary. It is not entirely certain whether the haemorrhage was exacerbated by deranged coagulopathy due to her liver disease.
Copies sent to
representatives of University Hospitals of Leicester NHS Trust CMS Lawrepresentatives of the general practitioner

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Report details

Reference
2022-0261
Date of report
31 March 2022
Coroner
Dianne Hocking
Coroner area
Leicester City and South Leicestershire

Responses identified

Responses identified 1 of 1
All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 28 Nov 2022 (estimated).

Sent to

Department of Health and Social Care

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