Source · Prevention of Future Deaths

Margaret Dempsie

Ref: 2016-0374 Date: 24 Oct 2016 Coroner: Dianne Hocking Area: Leicester City and Leicestershire South Responses identified: 3 / 2 View PDF

Hospital discharge letters contained significant inaccuracies and omissions, often completed by junior doctors who hadn't seen the patient, risking serious care mistakes for vulnerable patients.

Date 24 Oct 2016
56-day deadline 19 Dec 2016 est.
Responses identified 3 of 2
Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary
Hospital discharge letters contained significant inaccuracies and omissions, often completed by junior doctors who hadn't seen the patient, risking serious care mistakes for vulnerable patients.
View full coroner's concerns
The discharge letter from the University Hospitals of Leicester NHS Trust addressed to the primary care team contained inaccuracies. It stated that Mrs Dempsie had been suffering from aspiration pneumonia when no pneumonia had been identified and did not mention pyelonephritis, which had been present. The Consultant who was looking after Mrs Dem sie was not sur rised and admitted in the in uest that the Dischar e

Letters for patients were being completed with mistakes by the Junior Doctors, that this was something that happens and that GP's regularly have to phone the hospital to ascertain the correct facts. He said that sometimes the junior doctors who complete the discharge letters have never seen the patient. This situation was also confirmed by the General Practitioner who was also present at the inquest. I have concerns that the wrong information is being passed on to primary carers who are then, of course, obliged to act upon the information they are furnished with in the Discharge Letter and that this could lead to serious mistakes, being made in the care of vulnerable patients newly discharged from hospital. I. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action.

Responses

3 respondents
NHS England NHS / Health Body
24 Oct 2016 PDF
Noted

NHS England acknowledges the concerns and states that the Leicester City Clinical Commissioning Group (CCG) is responsible for commissioning services from the University Hospitals of Leicester NHS Trust. They have asked the CCG to respond and provide assurance regarding actions taken and have reviewed the CCG's response, finding the identified actions robust. (AI summary)

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Dear Mrs Hocking, RE: Margaret Mary DEMPSIE Professor Sir Bruce Keogh National Medical DErec#ar Skipton House 80 ~.andon Road SE1 6LH It~y~ December X016 Thank you far your letter and report dated 24 October 2016, recEived by my office on 27 October 2016. I was vory sorry to read of the circumstances around Margaret's death, and wouid like to express my deep condolences to the D~mpsie family. have reviewed your report in detail and I have identified that the Leicester City Clinical Commissioning Group ("CCG") is responsible for commissioning services tram the University Masplt~ls of Leicester NM5 Trust. I have therefore asked the CCG to respond and provide assurance regarding actions they have taken in order to mitigate the risk identified within your report. A copy of their response is enclosed with this letter. have reviewed the response from the CCG and am assured that the actions identified are robust. hope this is of some assistance to you and will help to prevent future deaths. In the mean#ime, if you have any further queries please do not hesitate to contact rne.
University of Leicester NHS Trust NHS / Health Body
15 Dec 2016 PDF
Action Planned

University Hospitals of Leicester NHS Trust has reviewed medical records, discussed the case with the consultant and junior doctor involved, will strengthen the "Letters Policy" by January 2017, and will audit discharge letters with GP feedback, reporting to the Executive Quality Board in March 2017. (AI summary)

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Dear Mrs Mason Re Margaret Mary Dempsie write further to the Regulation 28 Report sent by your Assistant Coroner on the 24t" October 2016. In that Report concerns were raised about the accuracy of the information sent to GP's by junior doctors. Understandably your Assistant Coroner was concerned that primary carers are reliant upon the information provided to them in discharge letters and that if that information is incorrect then patients could come to harm. As a result of this Regulation 28 Report, the medical records of Mrs Dempsie have been reviewed by , Associate Medical Director &Consultant Physician, who has concluded that the discharge letter should not have referred to the patient as having had bronchopneumonia. However in this case, whilst the patient was clearly unwell and required end-of-life care following discharge; no harm befell Mrs Dempsie as a result of this inaccurate information being provided to her GP. The process for compiling a discharge letter at the Trust should be a joint enterprise between the junior doctor and the most senior clinician on the ward at the time that the discharge letter is signed off. Information contained in the. discharge letter should reflect that contained in the patieni's ~~nedical records and best practice occurs when the discharge letter is prepared in real time at the point the decision to discharge the patient is 'made in order to ensure that senior members of the clinical team involved in the care of the patient are involved in the process. Consultants ultimately have responsibility in providing clinical leadership to their junior teams to ensure that this process is supported. Our Medical Director has noted that the consultant in this case appears to have raised concerns with your Assistant Coroner that discharge letters for patients under their care regularly contained inaccuracies and so will be meeting 1 University Hospitals of Leicester NHS Trust includes Glenfield Hospital, Leicester General Hospital and Leicester Royal Infirmary. Website: www.leicestershospftals.nhs.uk Chief Executive: Mr John Adler

with the consultant involved to understand what actions they have taken to address this and as to whether he has raised this as a concern with the Trust. Whilst we strive to ensure that all discharge letters contain all relevant and accurate information, we recognise that we do not get this right on every occasion. To minimise the risk of inaccurate information being provided to GP's, the Trust has developed a standardised template for discharge letters which detail the reason for admission and main diagnosis at discharge. Additionally the Trust provides an e- learning package for junior doctors to reinforce the importance of providing accurate information to GP's. Approximately 500 GP concerns per year come through the Patient Safety team and these are themed and discussed at the Clinical Quality Review Group. The Senior Patient Safety Manager and the Head of Services for GPs now meet monthly to triangulate GP concern themes to monitor these and inform required actions at Trust wide level. In addition, the Trust has for some time requested individualised feedback from GP's regarding any poor or inaccurate information received from the Trust and undertakes regular audits to pro~~ide assurance on the quality of the information provided in Discharge Letters. These audits show an improvement in the quality of the information that we provide to GP's. As a result of this case the Trust has taken and will be taking the following actions:- The frequency of internal audits for discharge letters will be increased for each CMG every month with immediate effect and our Head of Outcomes and Effectiveness will lead on this.
2. Our Chief Medical Information Officer and Head of Services for GP's will encourage GP's to provide individualised and patient specific feedback concerning poor discharge letters throughout December 2016 to assess the level of inaccuracies and perception of poor Discharge letters. Our Chief Medical Information Officer will then review any feedback and discuss necessary actions with the doctors involved and the GP dependent upon the findings. He will report on this matter to the Executive Quality Board in March
2017. Our Head of Services for GP's will promote the opportunities to feedback errors on discharge letters directly to her in the December GP Newsletter. This extended audit will then be repeated at regular intervals, depending on the findings.
3. Our Head of Effectiveness and Outcomes has raised the issue requesting GPs to provide feedback concerning incorrect discharge letters at the Clinical Quality Review Group Meeting on 17 November 2016. This review Group includes GP leads for the Clinical Commissioning Groups
4. Our Medical Director will ensure that this case is discussed with the Consultant involved before the end of December 2016 to encourage reflective learning. has met with the junior doctor who wrote the discharge University Hospitals of Leicester NHS Trust includes Glenfield Hospital, Leicester General Hospital and Leicester Royal Infirmary. Website: www.leicestershospltals.nhs.uk Chief Executive: Mr John Adler

letter in this matter. She has reflected upon this case and clearly understands the importance of accurately completing discharge letters in future.
5. Our Head of Outcomes and Effectiveness will strengthen our "Letters Policy" to ensure that there is clarity concerning the process for discharge letters and the importance of senior medical oversight. This should go to the Policy and Guideline Committee Meeting in January 2017. trust that this response assures you that we are take these matters seriously and if you wish for any further information please do not hesitate to contact me.
Leicester City Clinical Commissioning Group NHS / Health Body
PDF
Action Taken

Leicester City CCG has worked with University Hospitals of Leicester (UHL) to improve discharge information by reviewing systems, auditing discharge letters monthly, discussing the Regulation 28 Report at the Clinical Quality Review group, and planning to include a quality indicator in the 2017/2018 contract with UHL. (AI summary)

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Dear Mrs Hocking, Tel: b116 295 0750

am writing in response to your letter of the 1s1 of November 2016 regarding the Regulation 28 Report issued on the 24t" of October 2016 regarding the deafh of Mrs Dempsie. This CCG and our two commissioning partners in Leicestershire and Rutland recognise that the provision of accurate and timely discharge information is a pre requisite for safe and high quality patient care. We have been working together with University Hospitals of Leicester (UHL) to address this and have taken a number of concrete actions:- A group of clinicians and managers within UHL considered and reviewed the systems and processes underpinning the production of discharge letters. This group identified that there are a number of different IT systems within the trust that prevent the production of a standardised discharge letter format. An LLR wide discharge group is now looking at these IT issues, primarily focusing on the process for the electronic transfer of discharge letters to Primary care. Overview of this work is via the LLR informs#inn strategy group and will be via the. UHL Contract tEam next year.
• UHL undertakes an audit of a sample of discharge letters on a monthly basis, assessing their content and timeliness, with feedback directly to the clinician concerned. The trust reports that they have seen an improvement in bath the quality and the accuracy of letters since this started. This monthly audit will continue, and the results will now be reported into the CCGs Contract team for formal overview.
• To ensure that learning from this case is disseminated across the trust, the Regulation 28 Report was included as an agenda' item at the November Clinical Quality Review group to enable further joint discussion between the mast and the CCG and to consider any
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other actions that are being planned within the trust r~Iating fa the {ssue of Discharge letter accuracy. Getting accurate feedback from GPs whanever there is a problem with Discharge letters is a key part of improving performance. We are currently in discussion with UHL and our GP Calieagues about how this can best be done, probably through a dedicated email contact point. The intention is #a get feedback wi#hin 24 to 36 hours of receipt of the letter, with rapid contact wifh the reievant junior doctor both to increase their learning but also to ensure the provision of a corrected an accurate discharge letter where necessary. We are exploring the feasibility of this over the coming weeks.
• To ensure there is an ongoing focus an the quality of Discharge lettErs, the 2017 i 2018 contract with UHL will include a quality indicator within the contract which will be formally monitored and reported to the contract team. This wlkl include discussions around corrective action should the necessary improvements not be sustained, The contracts are due to be agreed by the 23~d of December 2016. o The CCGs are currently in discussion with UhIL about the content of their junior doctors Induction programme. We will ensure that an item is included within this programme which highlights the importance of getting accurate information out to primary care colleagues as soon as possible to ensure the appropriate delivery of care to patients. and the Governing body have citEd an the issues related to the discharge process and we are satisfied that we are working with the trust and our partners to seek ways to continualiy improve the quality and timeliness of Discharge tett~rs.

Report sections

Investigation and inquest
On 22 June 2016 I commenced an investigation into the death of Margaret Mary Dempsie. The Inquest concluded on 24 October 2016 Cause of death: 1a Septicaemia 1 b Bilateral Pyelonephritis (Proteus bacteria) 2 Dementia and frailty of old age. Coroners Conclusion: Natural Causes.
Circumstances of the death
Mrs Dempsie had lived in a residential care home where she had District Nurses and her General Practitioner visit her to give treatment for infected leg ulcers for more than one year. Her past medical history included advanced dementia, hypertension and arthritis. She was eventually admitted to the Leicester Royal Infirmary on the 04 April 2016 for treatment of her leg ulcers and she was recovering and awaiting a package of care for her discharge when she suddenly deteriorated and it was apparent that she was, once again, suffering from sepsis. There was nothing more than could be done and Mrs Dempsie was discharged for end of life care to a nursing home and she died there 2 days later. She was under a Deprivation of Liberty Safeguarding Order at the time of her death.
Copies sent to
24/10/2016

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Report details

Reference
2016-0374
Date of report
24 October 2016
Coroner
Dianne Hocking
Coroner area
Leicester City and Leicestershire South

Responses identified

Responses identified 3 of 2
All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 19 Dec 2016 (estimated).

Sent to

NHS England
University Hospitals of Leicester NHS Trust

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