Source · Prevention of Future Deaths

Nigel Handscomb

Ref: 2018-0278 Date: 1 Aug 2018 Coroner: Philip Barlow Area: London Inner (South) Responses identified: 0 / 1 View PDF

Incomplete and inaccurate GP consultation notes, made several hours after the fact, failed to record critical patient information, including examination findings and medication adherence, alongside unrecorded verbal instructions.

Date 1 Aug 2018
56-day deadline 27 Sep 2018
Responses identified 0 of 1
Community health care and emergency services related deaths

Coroner's concerns

AI summary
Incomplete and inaccurate GP consultation notes, made several hours after the fact, failed to record critical patient information, including examination findings and medication adherence, alongside unrecorded verbal instructions.
View full coroner's concerns
_ During your evidence to the inquest it became clear that the notes you had made of your consultation with Mr Handscomb were incomplete and inaccurate. Although in this case accepted that this did not cause or contribute to the death am concerned that; if repeated, it may do so in other cases. The inquest was told that GP records will now be more readily available to hospitals and will therefore inform their decision making processes Your records were made several hours after the consultation You did not record that You had carried out a chest examination, or the result of and July the The this examination: You did not record that Mr Handscomb had told you that he had not taken his Iithium medication for several days. This was of particular importance in view of the possibility that his symptoms might be the result of Iithium toxicity.

(4) You did not record that you carried out a swallow test and that Mr Handscomb could not swallow.

(5) You prescribed medication and recorded that it should be taken once a day in the morning: This was the instruction recorded on the medication packet Your evidence was that you told Mr Handscomb to take the medication that afternoon This was not recorded.

Report sections

Investigation and inquest
On 12 September 2017 commenced an investigation into the death of Nigel Handscomb, age 65. The investigation concluded at the end of the inquest on 27 2018 The conclusion of inquest was: Medical cause of death: 1a) Aspiration pneumonia 1b) Bronchopneumonia Severe ketoacidosis Conclusion Natural causes to which neglect contributed
Circumstances of the death
Mr Handscomb was seen by you at the GP surgery on 18 August 2017. Later that day he was admitted to University Hospital Lewisham (UHL) He was found to have pneumonia and possibly to have suffered a stroke. At UHL he was not reviewed by a doctor for 48 hours and opportunities to escalate his care were missed. Mr Handscomb suffered a cardiac arrest and died on 21 August 2018.
Action should be taken
In my opinion action should be taken to prevent future deaths and believe you have the power to take such action_

Similar PFD reports

Shared signals

Related inquiry recommendations

Similar themes

Report details

Reference
2018-0278
Date of report
1 August 2018
Coroner
Philip Barlow
Coroner area
London Inner (South)

Responses identified

Responses identified 0 of 1
1 response not yet linked

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 27 Sep 2018.

Sent to

Eden Park Surgery

Source links