Source · Prevention of Future Deaths

Edward Gascoigne

Ref: 2015-0401 Date: 7 Oct 2015 Coroner: R Brittain Area: London Inner (North) Responses identified: 1 / 1 View PDF

The report identifies that relevant information about the deceased's illness was in disparate records, making it difficult for clinicians, especially the psychiatric team, to access and share.

Date 7 Oct 2015

56-day deadline 2 Dec 2015 est.

Responses identified 1 of 1

Community health care and emergency services related deaths

Coroner's concerns

AI summary

The report identifies that relevant information about the deceased's illness was in disparate records, making it difficult for clinicians, especially the psychiatric team, to access and share.

View full coroner's concerns

During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. The MATTERS OF CONCERN are as follows. –

(1) Multiple pieces of relevant information regarding Mr Gascoigne’s current illness were contained in disparate record ‘silos’. It was difficult for clinicians to access this information and, as such, it was not available to the reviewing psychiatric team, in particular.

I am concerned that the previous focus on access to medical records, which was to occur through the NHS Programme for IT, has been lost and that the new focus on patient access to GP records will not address the risks posed by the current state of record sharing within the NHS.

Responses

1 respondent

Response ny Department of Health Central Government

7 Oct 2015 PDF

Noted

The Department of Health describes the Summary Care Record (SCR) system and planned enhancements, stating that it is designed to improve access to patients’ GP records. (AI summary)

View full response

Rt Hon Alistair Burt MP Minister of State for Community and Social Care Department of Health Richmond House 79 Whitehall London SWIA 2NS POCOOOO1002339 Tel: 020 7210 4850 Mr R Brittain Assistant Coroner St Pancras Coroners Court Camley Street 0 2 DEC 2015 London NIC 4PP Dex m &le : Thank you for your letter of 7 October 2015,following the inquest into the death of Edward Gascoigne: Iwas sorry to hear of Mr Gascoigne's death and wish to extend my condolences to his family. This case highlights issues about the sharing of patient information within the NHS. You are rightly concerned about access to patient'_ s GP records by treating clinicians and indicated that you feel that the current system of record sharing in the NHS will pose risks to patient care: It is vital that the effective treatment of patients is underpinned by timely and appropriate transfer of information that follows the patient through the healthcare The current system of sharing GP patient records is via the Summary Care Record (SCR) To date; more than 96% of people in England have had SCRs created and uploaded onto the NHS National Spine; a national infrastructure that stores electronic patient information: SCRs contain information sent electronically from the GP record to be held securely on the National Spine Core data in all SCRs comprises: details of Medications (Long-term, Acute and recently discontinued); known Allergies and Adverse Reactions This information is kept up-to-date in real time. In most SCRs, the Core data also contains the *date of last issue' of medications, which gives an indication of whether the patient is the medication regularly: key system: taking

Department of Health for use by commissioners for all contracts for healthcare services other than primary care). To quote the relevant section: '23.6 Subject to General Condition 21 (Patient Confidentiality, Data Protection, Freedom of Information and Transparency) the Provider must ensure that all Staff involved in the provision of urgent, emergency and unplanned care are able to view Service User clinical information from GP records, whether via the Summary Care Records Service or a locally integrated electronic record system supplemented by the Summary Care Records Service. In addition, NHS England's business plan for 2015/16, which sets out priorities for the coming year; has mandated SCR access for 11l services, 999 services and hospital acute admission areas. To quote from the section, Commitments for redesigning urgent and emergency care services: 'By March 2016 complete information sharing across 1ll, 999 and hospital acute admission areas to at least a minimum of Summary Care Record, including end of life and advanced care plans. Furthermore, NHS England is working with partners to develop a range of tools and guidance to support commissioners and providers in the transformation of urgent and emergency care services. This includes the development of an enhanced summary care record which will enable greater access to patient care plans, including end of life care records, special patient notes and mental health crisis notes [ hope I have reassured you that Government plans for sharing of patient information is a priority for urgent and emergency care and that the current SCR system is designed to improve access to patient'$ GP records so that important and vital patient information is available to all treating clinicians. I am grateful to you for bringing the circumstances of Mr Gascoigne's death to my attention and trust that you find this reply helpful. AL seix Acl(4 ALISTAIR BURT key

Report sections

Investigation and inquest

Edward Gascoigne died on 8 May 2015, aged 80 years old, from injuries sustained after he was hit by a tube train. An inquest into his death was heard on 29 September 2015, at which I recorded a narrative conclusion (see attached).

Circumstances of the death

Mr Gascoigne had a background history of some depressive episodes. In the few weeks before his death he had reported increasing episodes of confusion and low mood. This prompted attendance at his General Practitioners’, who started antidepressant medication and referred him to community mental health services. One GP involved in his care also noted that he had stopped taking medication to treat hypothyroidism.

Before Mr Gascoigne was seen by the mental health team, he reported a worsening of his symptoms and was admitted to A&E at the Royal Free Hospital. He was noted to have moderate depression and was admitted overnight, for input from the psychiatric liaison team.

The admitting doctor noted a more significant history than had been appreciated, including two episodes of suicidal plans, the last being three years previously. Mr Gascoigne denied any current suicidal thoughts or plans. It was not noted that Mr Gascoigne had stopped his thyroid medication, nor that he had been prescribed antidepressants. Neither was it documented that the GP had referred to community psychiatry already. The hospital doctors were not able to access Mr Gascoigne’s GP records in order to ascertain this information, which does not appear to have been volunteered by the patient himself.

The situation was discussed with the psychiatric liaison team, who advised that Mr Gascoigne be referred to community psychiatry. The Trust providing liaison psychiatry at the Royal Free Hospital was different from the Trust who provided community psychiatry at Mr Gascoigne’s home address. As such, they were unable to appreciate that this referral had already been undertaken.   After being informed that that he was not going to be reviewed by psychiatry as an inpatient, Mr Gascoigne became angry and frustrated. He was formally discharged at this point and shortly afterwards was found deceased at an underground station, having been hit by a train. There was CCTV evidence that no third party was involved in this incident.

I heard evidence at the inquest that, had the additional relevant information been available to the psychiatric liaison team, it is probable that Mr Gascoigne would have been reviewed as an inpatient. However, it was also likely that Mr Gascoigne would still have been discharged for review by the community team.

Copies sent to

I am also under a duty to send the Chief Coroner a copy of your responseAssistant Coroner R Brittain

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Report details

Reference: 2015-0401
Date of report: 7 October 2015
Coroner: R Brittain
Coroner area: London Inner (North)

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: 2 Dec 2015 (estimated).

Sent to

Department of Health and Social Care

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.