Lewis Doyle

Coroner's concerns

AI summary

Discharge letters for patients with complex conditions are not being sent to all relevant medical attendants, leading to a lack of critical information for original prescribers regarding suspended medications.

View full coroner's concerns

The MATTERS OF CONCERNS are as follows: When Mr Doyle was discharged from the Liverpool Heart and Chest Hospital the GP discharge letter was sent to his GP. Mr Doyle was receiving treatment for Acute Coronary Syndrome but also mental health care for a Recurrent Depressive Illness (without Psychosis). Lithium had to be stopped not only because it was at a toxic level but also because of the effect of this and alternate medications on cardiac health. It occurred during the inquest that in similar scenarios better patient care could be delivered, if discharge letters were sent to all current medical attendants, whether in primary, secondary or tertiary care. Information with regarded to suspended or stopped medication was needed by the original prescribers.

Responses

2 respondents

Department of Health and Social care Central Government

24 Jun 2019 PDF

Noted

The Department of Health and Social Care acknowledges the concerns about communication between medical practitioners and refers to existing NHS Standard Contract requirements and professional duties regarding information sharing, but does not commit to specific new actions. (AI summary)

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From Nadine Dorries MP Parliamentary Under Secretary of State for Mental Health, Department Suicide Prevention and Palient Safety of Health & Social Care 39 Victoria Street London SW1H OEU 020 7210 4850 Your Ref: 00123-2019 Our Ref: PFD-1188207 Mr Andre Rebello HM Senior Coroner; Liverpool and Wirral Gerard Majella Courthouse Boundary Street Liverpool Merseyside LS 2QD 'th January 2020 M Pzbell o, Thank you for your correspondence of 24 June 2019, received by the Department of Health and Social Care on 27 August 2019, about the death of Mr Lewis James Doyle. Iam replying as Minister with responsibility for patient safety and I am grateful for the additional time in which to do s0. Firstly, I would like to say how saddened I was to read of the circumstances of Mr Doyle's death and [ extend my deepest sympathies to his family and loved ones. Ihave noted the concerns in your report about ineffective communication between Mr Doyle's medical practitioners and your recommendation that all medical attendants involved in a patient's care should be sent discharge letters to ensure that are aware of 'changes to that patient's medication: Iam aware that NHS England and NHS Improvement has advised you in its response of the requirements under the NHS Standard Contract 2019-20' for providers of care to share information on the discharge of patients, or transfer of their care, and that supporting guidance? recommends that information on medications should include those that have been stopped and the reasons why: https: MWW england nhs uklwp-contentuploads/2019 03/3-FL-SCs-L920-sepsis pdf https: theprsb org/wp-contentJuploads 2019 02 eDischarge-Summary-Maintenance-Release-Implementation Guidance-Repor-V2 L23.L9 pdf they

More generally, clinicians have a duty to share information about their patients as consider appropriate Section 251B of the Health and Social Care Act 201234 places a duty on health and social care providers to share information about an individual with other health and care providers where it is likely to facilitate the care provided to the individual and is in their best interests. In addition; health professionals owe a duty of care to those treat and this includes ensuring that information about their direct care is shared appropriately with other health and care professionals The General Medical Council (GMC) regulates doctors in the UK The GMC s guidance; Good Medical Practices, sets out the standards that doctors should meet in order to practice in the UK. This includes sharing *relevant information with colleagues involved in your patients " care within and outside the team In addition, the GMC s ethical guidance on Leadership and Management' , says that 'It is essential for and safe patient care that doctors work effectively with colleagues from other health and social care disciplines. both within and between teams and organisations Iam advised that these legal and professional duties provide a clear framework for the effective sharing of information to support the care and treatment of patients, enabling medical professionals to make decisions on a case by case basis about the information that should be shared. [ expect the local NHS to consider carefully the care provided to Mr Doyle and to take action where necessary to implement any learnings: While we do not believe that imposing further requirements to share data are necessary, the Government is committed to supporting the work of the Medicine Safety Improvement Programme , led by NHS England and NHS Improvement, which aims to increase safety across the medication pathway, including in areas such as regular medication reviews and safe patient discharge. http: ( www legislation gov ukyukpg./2042/ 7 contents enacted htlp:/ www legislation Eov ukJukpga/2015 28 crossheading continuity-of-information/enacted htups; www gmc-uk- ~orglethical-guidance ethical-guidance-for-doctors/good-medical_ praclice https: wwwgmc-ukorg ethical-guidance ethical-guidance-for-doctors/leadership-and-management-for-all-doctors https: improvement_nhsuklresources national-medicines-safety-programme they they good

The Medicine Safety Improvement Programme will together a variety of projects to support medicine safety, from engaging patients as their own safety advocates, through to improvements to technology, to enabling the workforce to operate safely with strong systems and practices, to prevent harm: Iam aware that NHS England and NHS Improvement has provided more detail in its reply to you on the work that is place to support the NHS with better technology to improve access and sharing 0f, clinical information. I hope this response is helpful. Nsl e NADINE DORRIES bring taking to,

NHS England NHS / Health Body

18 Dec 2019 PDF

Action Taken

NHS England and NHS Improvement are connecting organisations to the Cheshire and Merseyside health and care record sharing platform, which includes the ability to share discharge summaries and clinic letters, with technical completion due by March 2021. (AI summary)

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Dear Mr Rebello, Re: Regulation 28 Report to Prevent Future Deaths Lewis James DOYLE Thank you for your Regulation 28 Report (hereinafter the 'report) dated 24 June 2019 concerning the death of Mr Lewis James Doyle on 8 January 2019. Firstly, would like to express my condolences to Mr Doyle's family_ note you directed identical Regulation 28 letters to NHSE and to NHSI. NHS E&l are jointly operating and this reply has been prepared and sent on behalf of both organisations. Your recent inquest into the death of Mr Doyle concluded that he died as a result of Organising Pneumonia due to traumatic injuries to feet (with distal amputations), severe coronary artery disease and metastatic carcinoma of the prostate_ Following the inquest; you have now raised concerns in the report for the consideration of NHS England ' regarding specifically the communication and information systems between healthcare providers in primary, secondary and tertiary care with regard to suspended or stopped medication_ In the particular circumstances of Mr Doyle's death this related to the stopping ofLithium in connection with his cardiac health_ You suggest that there may be an opportunity to ensure all healthcare providers involved with a patient are included in any discharge information with regard to such decisions to suspend or medication_ We know from the evidence and.National Reporting and Learning Service (NRLS) that the transition of care is a high-risk situation: This is reiterated in the World Health Organisation (WHOmedication without harm challenge priority (https Ilapps who intliris/bitstream/handle/10665/325453NHO-UHC-SDS-2019.9 eng pdf?uaz1 ) confim that the UK is responding to this challenge from the WHO through the National Medication Safety Programme being jointly run by the Department of Health and Social Care (DHSC) and NHS England and Improvement (NHSEII): This NHS England and NHS Improvement his stop can

programme includes objectives on systems and practices that; amongst other covers the following points relevant to this case: The accelerated roll-out of hospital e-prescribing and medicines administration systems New systems linking prescribing data in primary care to hospital admissions The development of a prioritised and comprehensive suite f metrics Whilst discharge summaries remain the responsibility of individual trusts, the NHS standard contract expects the transfer of information within 24 hours of discharge usually from provider to GP_ The Discharge information should contain a full and accurate summary record of medications (both prescribed and non-prescribed) including any that were discontinued and any reasons for this in line with recommendations from The Academy of Medical Royal Colleges (AoMRC) and the Professional Record Standards Body (PRSB): The use of Dictionary of medicines and Devices (dm+d), (a dictionary of descriptions and codes for medicines and devices in use across the NHS), compliant Electronic Prescribing and Medicines Administration (EPMA) systems makes the process of sending and receiving medicines related information between organisations and health professionals easier and more accurate: It is recognised that this would improve patient safety and hence there is now national funding to support its roll out. can confirm that NHS Ell provided funding for an additional 25 Trusts to have EPMA in this last week The information standards for digital transfer of care do include changes to medicines albeit optional at present: These will be used for the basis for transfer of care in the future (PRSB standards https Iltheprsb orglstandardsledischargesummaryl) As well as the funding for the EPMA roll out nationally there is support for Trusts regarding transfer of care around medicines from the Academic Health Science Networks (AHSNs) AHSNs are supporting the implementation of systems to facilitate improved communication about medicines between healthcare sectors in line with evidence to show what works. This is designed to improve communication between hospital, community and primary care pharmacists including around discharge. The work is being led by Wessex AHSN on behalf of the AHSN network and uses technology and proven audit tools to facilitate this transfer: NHS Ell is closely involved in this work_ In the North West Region, SharezCare (S2C) is a programme of work that stretches across the North West Coast of England Covering the organisations of Lancashire and South Cumbria Integrated Care Systems (ICS) and Cheshire and Merseyside STP (Sustainable Transformation Programme): The programme is nationally funded digital and transformational programme that is part of the national Local Health and Care Record (LHCR) programme. S2C is classed asa wave 2 LHCR with several ICSISTPs already 2 years into the programme: S2C is an evolving programme in its Ist full of deployment: In the Cheshire and Merseyside health The Professional Record Standards Body (PRSB) provides professional and patient endorsed and evidence based clinical record standards which include discharge summary standards. The Academy of Medical Royal Colleges (AoMRC) "Standards for the Clinical Structure and Content of Patient Records" , published in 2013, were adopted by the PRSB, since it was established in 2013. This standard defines the headings, with descriptions, for electronic records based on a number of specified use cases (admission , referral, discharge, outpatient letter; and handover): NHS England and NHS Improvement things, year

care organisations are being connected to the sharing platform in stages. This is an iterative process that will see the clinical and eventually social care data available to view increasing: Currently the ability to share discharge summaries and clinic letters is in place across the . organisations that have been connected to date_ The programme will also include a link to Lancashire &South Cumbria that will enable sharing of records across borders. North West Ambulance Service (NWAS) is also working with the programme to enable them to connect to the sharing platform. The programme is due to technically complete by March 2021; the improvement in the richness of data will also continue to develop beyond programme life cycle. Thank you for bringing this important patient safety issue to my attention and please do not hesitate to contact me should you need any further information

Report sections

Investigation and inquest

On 17/01/2019 I commenced an investigation into the death of Lewis James Doyle aged 80. The investigation concluded at the end of the inquest on 24 June 2019. The conclusion of the inquest was: An accidental death The Medical Cause of death was I a Organising Pneumonia I b Traumatic injuries to feet (with distal amputations), severe coronary artery disease and metastatic carcinoma of the prostate I c II

Circumstances of the death

Mr Lewis James Doyle had a past medical history of Coronary Artery Disease, Parkinson’s disease, Cerebral meningioma, Adenocarcinoma of the prostate & a longstanding recurrent depressive illness (without psychosis) for which he was prescribed fluoxetine, mirtazapine and lithium. On 10th September 2018, Mr Doyle was admitted to Arrowe Park hospital following an episode of Acute Coronary Syndrome. On the 14th September 2018, a decision was made to suspend lithium medication, as the level was 1.4, which was biochemically toxic. On the 20th September 2018, the Lithium was stopped and later the same day Mr Doyle suffered a cardiac arrest. On 24th September 2018, Mr Doyle was transferred to Liverpool Heart & Chest Hospital where he underwent a procedure to insert coronary artery stents and an internal cardiac defibrillator before being discharged home. On 22nd October 2018, Mr Doyle was seen by his General Practitioner for a review of medication relating to his enlarged prostate. At 12.53 on the 22nd October 2018, Mr Doyle fell in front of a train at Bebington Railway Station. Mr Doyle was disorientated in thought and there is no evidence that he intended to self-harm. It is possible that he was experiencing a psychosis. Mr Doyle suffered head and lower limb injuries was taken to University Hospital Aintree where he underwent a bilateral foot amputation. On 30th October 2018 after a discussion between a Merseycare psychiatrist and a University Hospital Aintree cardiologist, the decision was made to re-introduce lithium to Mr Doyle. It is found that Lithium had to be stopped when it was at a toxic level and there were no alternatives for mood stabilisation, which did not carry a risk to his cardiac health. The Lithium was reintroduced when Mr Doyle was medically stable minimising the risk of a further cardiac event. On 17th November, once stable Mr Doyle was transferred to Arrowe Park Hospital to continue his treatment on the orthopaedic ward. During his time at Arrowe Park, Mr Doyle developed a chest infection for which he was treated with antibiotics, which were escalated when his symptoms worsened, he became breathless and his oxygen requirements increased. Chest X-Rays demonstrated pulmonary oedema & furosemide was then added to clear his lungs. On 8th January 2019, it appeared there was no clinical improvement and furthermore Mr Doyle was deteriorating. The decision was made to turn off the internal cardiac defibrillator to prevent painful & inappropriate shocks. Mr Doyle passed away and his death was confirmed at 20:58 on 8th January 2019.

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 19 August 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 I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: Mr Doyle’s family Wirral University Teaching Hospital Cheshire and Wirral Partnership I have also sent it to: Liverpool Heart and Chest Hospital The University Hospital Aintree Knowsley and St Helen’s NHS Foundation Trust The Royal Liverpool University Hospital Trust who may find it useful or of interest. 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. Andre REBELLO Senior Coroner for Liverpool and Wirral Dated: 24 June 2019

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