Source · Prevention of Future Deaths

Alan Jones

Ref: 2015-0059 Date: 18 Feb 2015 Coroner: Paul Bennett Area: Swansea & Neath Port Talbot Responses identified: 1 / 4 View PDF

Inadequate GP training on electronic patient systems hindered access to critical clinical information. Software design failures also prevented important patient conditions from being clearly highlighted as alerts.

Date 18 Feb 2015

56-day deadline 15 Apr 2015 est.

Responses identified 1 of 4

Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary

View full coroner's concerns

The evidence of both of the GPs involved in Mr Jones'$ care, as well as that of the GP expert, clearly highlighted issues with the use of the electronic data on the patient system. These were: (1) An apparent lack of adequate training on the use of the software systems. This meant that important clinical information could not be made available easily. The expert GP gave evidence that this training deficit was not uncommon: He had the experience of using 4 different software programs in his career and had identical issues over lack of training: (2) An apparent failure in the software programs themselves to highlight important diagnosed conditions as an alert; when the patient record is opened and to prevent further steps taken to navigate the program (and make any entries) without consciously closing the "alert" first

Responses

1 respondent

Department of Health Central Government

27 Apr 2015 PDF

Noted

The Department of Health explains the GP Systems of Choice (GPSoC) scheme, through which the NHS funds the provision of GP clinical IT systems in England. (AI summary)

View full response

Dear Mr Bennett; Thank you for your letter to Dame Sally Davies following the inquest into the death of Alan Jones: I was very SOrTy to hear of Mr Jones' death and wish to extend my sincere condolences to his family: Mr Jones was patient in Wales. You have sent your report to NHS Wales and the Welsh Assembly Government as the appropriate bodies to respond to your concerns in this case. In addition, the Royal College of General Practitioners will be interested in the issues YOu raise. The Department of Health in England has however no responsibility for operational matters for general practice in Wales My comments therefore relate to the points YOu make about EMIS and GP record systems as apply in England Your concerns focus on both the capability and accessibility of EMIS as an electronic patient record system used in general practice, and the apparent lack of training for GPs in the use of this system and other such systems. Evidence given at the inquest clearly highlighted issues with the use of the electronic data on the patient record system: lack of adequate training on the use of the software systems. This meant that important clinical information could not be made available easily. The expert GP gave evidence that this training deficit was not uncommon A failure in the software programmes themselves either to highlight important diagnosed conditions as an alert, when the patient record is opened or to prevent any further steps taken to navigate the programme (and make any entries) without consciously closing the "alert" first: they being

In England GP practices have freedom to choose and implement their own IT systems and there are a number of GP systems available, including EMIS. This scheme is known as the GP Systems of Choice (GPSOC) through which the NHS funds the provision of GP clinical IT systems in England. GPSoC includes all the leading GP clinical IT systems in use in England. Following the introduction of GPSoC, practices can choose between systems provided either by their Local Service Provider (LSP) or by suppliers contracted to offer systems o the GPSoC Framework: The GPSoC Framework offers a number of benefits for GP Practices. Greater choice of centrally and locally-funded IT systems and services Central funding for patient facing services required to meet GMS contract obligations. Opportunity to hold Principal System suppliers to account; through GPSoC, for the delivery of service improvement plans Centrally-funded training for National Services such as the Electronic Prescription Service; GPZGP and the Summary Care Record: Further details about the GPSoC Framework and the systems available can be found on the GPSoC website: http IIsystems hscic_gov uklgpsoc The GPSoC is also available in Wales: However I understand that Welsh requirements are not the same as English GPSoC requirements, with the result for example, alert and message functions may vary: [ hope that this response is helpful and I am grateful to for bringing the circumstances of Mr Jones' death to my attention.

Report sections

Investigation and inquest

On 14th April 2011 commenced an investigation into the death of Alan Vaughan Jones aged 63_ The investigation concluded at the end of the inquest on 16"h January 2015. The conclusion of the inquest was Addison's Disease as a result of neglect

Circumstances of the death

The deceased had Addison's disease and required steroid replacement medication which had been prescribed by his GP. In early April 2011_ he developed gastroenteritis_ He suffered with diarrhoea and vomiting and was unable to take his oral medication. He became progressively weak and unable to get out of bed. He required intravenous steroid replacement: He had a telephone encounter with his GP who was unaware that he had been diagnosed with Addison's Disease. This was because the software program containing his data did not show it as a critical part of his medical history, When the consultation screen was opened. The system was the EMIS program_ The GP would be required to scroll through the whole of the past consultations or open a particular tab in the program to have seen the entry: In the context of a telephone consultation of 4 minute duration this was not considered to be unacceptable medical care Advice given by the GP was to maintain fluid balance and avoid dehydration: Had the GP known of the Addison's and the inability to take essential medication, his advice would have been different: The deceased's daughter met with a different GP that same April 2011) and did a review of the medical history: She was able to access the whole of the records, She identified his condition of Addison's disease, but did not make arrangements t0 visit the deceased at home that evening nor arrange for him to be admitted to hospital as an emergency His condition deteriorated and he died at 08.50 hours on the 8 April 2011. day

The evidence of the expert endocrinologist established causation, viz: that had he been admitted to hospital and received intravenous steroids ay any time up until midnight on the 7lh April he would not have died. A short form conclusion of neglect was returned

Action should be taken

In my opinion action should be taken to prevent future deaths and believe you ANDIOR your organisation has the power to take such action

Similar PFD reports

Shared signals

Related inquiry recommendations

Report details

Reference: 2015-0059
Date of report: 18 February 2015
Coroner: Paul Bennett
Coroner area: Swansea & Neath Port Talbot

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: 15 Apr 2015 (estimated).

Sent to

NHS England

NHS Wales

Royal College of General Practitioners

Welsh Assembly Government

Part of a series

2 reports

2021-0079 All responses identified

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.