Source · Prevention of Future Deaths
Yaser Saleh
Ref: 2014-0453
Date: 17 Oct 2014
Coroner: Andrew Harris
Area: London (Inner South)
Responses identified: 0 / 3
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The GP's computer system only prompts reviews for patients on regular prescriptions, failing to identify those with chronic diseases like asthma who are not currently prescribed medication but still require monitoring, posing a risk of preventable deaths.
Date
17 Oct 2014
56-day deadline
12 Dec 2014 est.
Responses identified
0 of 3
Coroner's concerns
The GP's computer system only prompts reviews for patients on regular prescriptions, failing to identify those with chronic diseases like asthma who are not currently prescribed medication but still require monitoring, posing a risk of preventable deaths.
View full coroner's concerns
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The MATTER OF CONCERN is as follows_ The GP reported that she believes that her EMIS computer system only called up people for review who were receiving regular prescriptions and thus a patient who had been on regular treatment but no longer was asking for inhalers was not identified as requiring call up for review: Whilst the court heard it was possible to customize the QOF system to call up patients, there was, according to the GP, no computerised system of calling up asthmatics who needed review unless they were currently on regular medication. She and the consultant in emergency medicine considered this created a risk of preventable deaths, that merited my making this report The consultant in emergency medicine also said that this risk applied to other chronic diseases, such as epilepsy: This risk of not identifying those at risk of death because they no longer comply or have not rebegun necessary treatment taken in the past is brought to the attention of EMIS and the Secretary of State, to consider whether EMIS has the potential or another electronic system should be commissioned to ensure that those with chronic disease requiring review and monitoring; are triggered for the attention of the GP onwider criteria than current prescribing, or if such a system is available that considers using it and other GPs are made aware of its use
The MATTER OF CONCERN is as follows_ The GP reported that she believes that her EMIS computer system only called up people for review who were receiving regular prescriptions and thus a patient who had been on regular treatment but no longer was asking for inhalers was not identified as requiring call up for review: Whilst the court heard it was possible to customize the QOF system to call up patients, there was, according to the GP, no computerised system of calling up asthmatics who needed review unless they were currently on regular medication. She and the consultant in emergency medicine considered this created a risk of preventable deaths, that merited my making this report The consultant in emergency medicine also said that this risk applied to other chronic diseases, such as epilepsy: This risk of not identifying those at risk of death because they no longer comply or have not rebegun necessary treatment taken in the past is brought to the attention of EMIS and the Secretary of State, to consider whether EMIS has the potential or another electronic system should be commissioned to ensure that those with chronic disease requiring review and monitoring; are triggered for the attention of the GP onwider criteria than current prescribing, or if such a system is available that considers using it and other GPs are made aware of its use
Report sections
Investigation and inquest
On 17th September, 2012, opened an inquest into the death of: Yaser Saleh, aged 15 years, died 13.09.12 concluded the inquest at a full hearing on 145h October 2014. The medical cause of death was Acute Asthma_ The collapsed with an arrest. The conclusion as to the death was natural causes
Circumstances of the death
Master Saleh was registered with a general medical practice in London: Evidence from a consultant physician and ambulance service senior paramedic was that cardio-respiratory arrest from acute asthma may occur very suddenly and is, as here; is refractory to resuscitation_ To prevent such deaths appropriate treatment must be given and medical advice sought earlier in an exacerbation: A respiratory nurse gave evidence that the National Report on Asthma Deaths identified under use of steroids as a cause of avoidable deaths and identified that electronic surveillance was needed of those not getting steroids; who need them. This received regular steroid inhalers in 2004 and presented to accident and emergency department in 2006 requiring restarting steroids_ Between 2003 and 2009 he attended A&E 6 times with asthma and had 3 non attendances at respiratory clinics_ We know that the family regularly visit Saudi Arabia and so that there availability for monitoring and prescribing was not continuous. His general practice last prescribed for in September 2008, and the attendance at A&E with uncontrolled asthma in 2009 did not trigger a GP review, as it would under todays arrangements
Action should be taken
In my opinion action should be taken to prevent future deaths and believe that EMIS_ andlor Secretary of State may have or know who has the power to take such decisions
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Report details
- Reference
- 2014-0453
- Date of report
- 17 October 2014
- Coroner
- Andrew Harris
- Coroner area
- London (Inner South)
Responses identified
Responses identified
0 of 3
3 responses not yet linked
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 12 Dec 2014 (estimated).
Sent to
- Department of Health and Social Care
- EMIS Health
- Iveagh Surgery