Source · Prevention of Future Deaths

Timothy Jones

Ref: 2016-0421 Date: 24 Nov 2016 Coroner: Louise Hunt Area: Birmingham and Solihull Responses identified: 1 / 4 View PDF

GP practice had poor record-keeping, unclear home visit request procedures, misclassified clinical tasks as 'admin', and a policy discouraging home visits for complex patients, leading to inadequate assessment.

Date 24 Nov 2016

56-day deadline 27 Jan 2017

Responses identified 1 of 4

Community health care and emergency services related deaths

Coroner's concerns

AI summary

View full coroner's concerns

have concerns about record keeping at the practice: The residential home records recorded that the GP had visited the patient on 25 May 2016, however the GP could not find a record of that visit in the electronic notes: It is vital the accurate records are kept of contact with patients clinical decisions made. heard evidence at the inquest that the residential home had requested several home visits from the GP, on 5 July 2016, 12 July 2016 and 13 July 2016,but the GP disputed this. The mechanism of communication within the GP practice caused concern in that several aspects of care were classified as "admin tasks" when they required further clinical assessment: The process of requesting documenting requests for_home visits needs to be clearer The role of_ and put day " and and

"admin tasks" needs to be clarified so that these are only used for true administration tasks_ There was no clinical assessment of the deceased by a GP after the 25 May 2016 despite his deteriorating condition and complex needs. The GP' s policy for home visits (copy attached) did not contain any reference to those with complex chronic conditions who were residents in care or residential facilities. The policy actively seeks to avoid home visits which may have influenced decision making in this case: The deceased was diagnosed with aspiration pneumonia when he was admitted to hospital. He was at high risk of aspiration pneumonia heard evidence that the best antibiotics for aspiration pneumonia are co-amoxiclav: The deceased was not prescribed these in the community he was given amoxicillin instead. Consideration needs to be given whether guidelines should be produced to clarify which antibiotics are required in specific situations

Responses

1 respondent

Solihull Clinical Commissioning Group NHS / Health Body

PDF

Action Planned

The CCG will send a communication and learning alert to all Solihull member practices highlighting concerns and learning in relation to recording requests for home visits, GP home visit policies, and classifications of administrative tasks. The CCG will ask the Local Medical Committee to discuss with its members the consideration of a Solihull wide home visiting policy and the BAAG to consider the inclusion of aspiration pneumonia within the local version of the Primary Care Guidelines. (AI summary)

View full response

Dear Mrs Hunt Your reference :

RE: Timothy Simon Jones (deceased)

Thank you for forwarding the Report to Prevent Future Deaths issued following the inquest of the above named individual.

I have read and considered the matters of concern outlined and propose the following actions.

 A communication will be sent to all Solihull member practices via the CCG communication mode ‘little and often’ to highlight the issues raised in the Regulation 28 report;  In addition a ‘learning alert will be issued to all Solihull member practices to highlight concerns and learning in relation to: o Recording of requests for home visits o GP home visit policies o Nursing/residential home requests for GP home visits o Classifications of administrative tasks  The CCG will ask the Local Medical Committee to discuss with its members the consideration of a Solihull wide home visiting policy;  Advice will be issued to practices in respect of record keeping;

 Key points from the case will be used to build service requirements for review of GP support to care homes

The Birmingham and Solihull Area Prescribing Committee has approved local antimicrobial guidelines which are promoted to practices. These guidelines are based on the PHE guidance for the management of common infections in Primary Care and are adapted for local use by the Birmingham and Area Antimicrobial Group (BAAG) which has representation from primary and secondary care across Birmingham. Neither the PHE guidelines nor the local version include a recommendation for aspiration pneumonia. The recommended antimicrobial therapy for community acquired pneumonia for adults is amoxicillin. In addition to the actions above we are asking the BAAG via our local microbiologist to consider the inclusion of aspiration pneumonia within the local version of the Primary Care Guidelines.

I do hope that the actions described in this letter provide you with the assurance that we have taken this matter seriously. We shall implement these actions to the timelines given in the attached action plan.

Report sections

Investigation and inquest

On 27 July 2016, commenced an investigation into the death of Timothy Simon Jones The investigation concluded at the end of an inquest on 24th November 2016. The conclusion of the inquest was due to natural causes_

Circumstances of the death

The deceased was known to suffer from Downs Syndrome; Epilepsy and Dementia. He required PEG feeding: He had frequent admissions to hospital with chest problems in the year before his death. He was admitted to Solihull Hospital on 13 July 2016 with difficulty breathing: He was treated for aspiration pneumonia and a DNAR order was in place: He was discharged on 15 July 2016 at 17.00. He was readmitted at 22.43 the same with a decreased level of consciousness and breathlessness thought to be due to further aspiration or hospital acquired pneumonia. He deteriorated and died on 17 July 2016 at 05.55_ Based on information from the Deceased's treating clinicians the medical cause of death was determined to be: 1a. PNEUMONIA
2. DOWNS SYNDROME. PEG FEEDING,DEMENTIA AND EPILEPSY

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

Report details

Reference: 2016-0421
Date of report: 24 November 2016
Coroner: Louise Hunt
Coroner area: Birmingham and Solihull

Responses identified

Responses identified 1 of 4

3 responses not yet linked

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 27 Jan 2017.

Sent to

Bright and Hove Clinical Commissioning Group

Pavillions

Richmond Medical Centre

Sussex Partnership NHS Trust

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.