Source · Prevention of Future Deaths
John Lloyd
Ref: 2015-0282
Date: 16 Jul 2015
Coroner: Christopher Woolley
Area: Cardiff and the Vale of Glamorgan
Responses identified: 0 / 2
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Frequent failures in the hospital's electronic system to notify GPs of patient admissions jeopardised continuity of care and could lead to inappropriate treatment courses and poorer outcomes.
Date
16 Jul 2015
56-day deadline
10 Sep 2015 est.
Responses identified
0 of 2
Coroner's concerns
Frequent failures in the hospital's electronic system to notify GPs of patient admissions jeopardised continuity of care and could lead to inappropriate treatment courses and poorer outcomes.
View full coroner's concerns
The MATTER OF CONCERN is as follows. and 29"h part 27th
For Mr Adam Cairns, Chief Executive, UHW The notification that should have been sent to the GP after the first admission to UHW on 29"h January 2015 was not sent heard evidence from that this was not an isolated incident but arose quite often particularly in times of stress (2) Itold me that an electronic system of notification had been introduced in mid-2014. This electronic system should therefore have been in place for Mr Lloyd but was not apparently utilised: Had this information been available to the GP then it may have caused more questions to be asked at his consultation on the 16lh February 2015 and may have led to a different course of treatment and outcome. The Coroner is concerned that UHW should employ systems to ensure the notification of admission to GPs in future cases to aid with the continuity of treatment: The Coroner is particularly concerned that failures in notification of admission occur quite frequently: For Dr Butler, UHW Cardiff informed me that he is now being put in charge of the notification system and that he intends to conduct an audit to ensure compliance He is therefore in a position to ensure that the electronic system of notification is used as intended. The Coroner is concerned thatl Ishould be given adequate support from the management of UHW to carry out his important role in overhauling the notification system to GPs
For Mr Adam Cairns, Chief Executive, UHW The notification that should have been sent to the GP after the first admission to UHW on 29"h January 2015 was not sent heard evidence from that this was not an isolated incident but arose quite often particularly in times of stress (2) Itold me that an electronic system of notification had been introduced in mid-2014. This electronic system should therefore have been in place for Mr Lloyd but was not apparently utilised: Had this information been available to the GP then it may have caused more questions to be asked at his consultation on the 16lh February 2015 and may have led to a different course of treatment and outcome. The Coroner is concerned that UHW should employ systems to ensure the notification of admission to GPs in future cases to aid with the continuity of treatment: The Coroner is particularly concerned that failures in notification of admission occur quite frequently: For Dr Butler, UHW Cardiff informed me that he is now being put in charge of the notification system and that he intends to conduct an audit to ensure compliance He is therefore in a position to ensure that the electronic system of notification is used as intended. The Coroner is concerned thatl Ishould be given adequate support from the management of UHW to carry out his important role in overhauling the notification system to GPs
Report sections
Investigation and inquest
On 4h March 2015 | commenced an investigation into the death of John Christopher Lloyd. The investigation concluded at the end of the inquest on 16"h July 2015. The medical cause of death was: 1.A Hypoxic Brain Injury 1B Overdose of Opiates_ returned a conclusion of accidental death:
Circumstances of the death
Mr Lloyd suffered a serious injury to his left foot in 2002, as a result of which he was in chronic pain for the rest of his life. He was prescribed painkillers and anti-depressants, including morphine. received evidence from several witnesses that he on occasion administered to himself an overdose of the morphine in order to control the pain: On 29"h January 2015he was admitted to UHW after having taken such an overdose_ He was seen by who was satisfied that it had been a therapeutic accident and not a suicide attempt. There is no criticism of the care he received between his admission on the January 2015 and his discharge on the 30lh January 2015. On discharge however no notification of the admission; whether by electronic means or paper was sent to Mr Lloyd's GP_ candidly accepted that such a notification should have been sent to the GP as continuity of treatment is desirable in such cases The GP was not therefore aware of this hospital admission until after Mr Lloyd's death (even though he held a consultation with him on 16th February 2015). Mr Lloyd's death occurred on the 27"h February 2015 at UHW following a second overdose which accepted was again an accident rather than deliberate. There is no criticism of the care of Mr Lloyd on the of UHW from the time of his second admission on 18ih February 2015 untii his death on the February:
Action should be taken
In my opinion action should be taken to prevent future deaths and believe that Mr Adam Cairns, Chief Executive, UHW and (2)L Consultant UHW have the power to take such action:
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Report details
- Reference
- 2015-0282
- Date of report
- 16 July 2015
- Coroner
- Christopher Woolley
- Coroner area
- Cardiff and the Vale of Glamorgan
Responses identified
Responses identified
0 of 2
2 responses not yet linked
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 10 Sep 2015 (estimated).
Sent to
- University of Wales, Cardiff
- University Hospital of Wales