Source · Prevention of Future Deaths

Silvia Taylor

Ref: 2014-0327 Date: 16 Jul 2014 Coroner: Martin Fleming Area: Surrey Responses identified: 1 / 3 View PDF

The service failed to act promptly on unsuccessful attempts to contact Mrs. Taylor and did not communicate these critical difficulties to her family, delaying potential intervention.

Date 16 Jul 2014

56-day deadline 10 Sep 2014 est.

Responses identified 1 of 3

Community health care and emergency services related deaths

Coroner's concerns

AI summary

The service failed to act promptly on unsuccessful attempts to contact Mrs. Taylor and did not communicate these critical difficulties to her family, delaying potential intervention.

View full coroner's concerns

During the inquest the following concerns arose: ‐

 Although initial reports from Mrs Taylor gave no concern for the need for urgent medical attention, unsuccessful attempts to contact her were not acted upon for several hours.  The difficulties in establishing telephone contact with Mrs Taylor, were not conveyed to the family.

I would ask that you consider giving further consideration to the no speech call procedures in relation to after hours support.

Responses

1 respondent

Care UK Private Sector

PDF

Action Taken

Care UK reviewed and updated its policy regarding procedures when telephone calls to patients needing assessment by the out-of-hours GP service are unanswered. (AI summary)

View full response

Dear Sirs Mrs Silvia Taylor (deceased) Regulation 28 report: action to prevent future deaths We are writing in response to HM Coroner's Regulation 28 report following the Inquest into the sad death of Mrs. Silvia Taylor on 7th February, 2013 (copy attached for reference). Paragraph 5 of the report states: "During the inquest the following concerns arose Although initial reports from Mrs Taylor gave no concern for the need for urgent medical attention, unsuccessful attempts to contact her were not acted upon for several hours: The difficulties in establishing telephone contact with Mrs Taylor were not conveyed to the family: would ask that you consider giving further consideration to the no speech call procedures in relation to after hours support Following receipt of the report we have reviewed and updated the policy as to how our current services should proceed if we make a telephone call to a patient and there is no reply (policy attached for reference)_ The policy has addressed two points where a patient may need contact from Care UK's out of hours GP service: Scenario 1 is where a patient's phone number has been received by the out of hours service because the patient needs further assessment over the telephone by a clinician: 2_ Scenario 2 is where the patient s phone number has been received by the out of hours GP service from the NHS 111 service because the NHS pathways algorithm has determined that the patient needs an appointment to be seen face to face Care UK Clinical Services Limited Primary Care Division: Registered In Ergland No 3462881 Registered Office: Connaught 850 The Croscent; Colchester Business Park, Colchester, Essex CO4 9QB Housc,

This policy change has happened in consultation with Care UK's senior doctors: National Medical Directors for Practices and for Health in Justice, Medical Director for Primary Care and the Regional Medical Directors within Primary Care This policy was ratified at the Clinical Quality and Goverance Committee Meeting for Healthcare on 22nd September;
2014.

Report sections

Investigation and inquest

On 14/2/13 I opened the inquest into the death of Silvia Eileen Taylor, who at the date of her death was 81 years old. The inquest was resumed and concluded on 14/7/14. I found that the cause of death to be:

1a – Ischaemic Heart Disease

I concluded with a narrative conclusion as follows: On 8/2/13, Silvia Eileen Taylor was found to have died at her home address of ischaemic heart disease. She had earlier activated her emergency pendant for the attendance of the doctor, although several subsequent attempts by the doctors to contact her by telephone were unsuccessful. It is found more likely than not, that earlier medical intervention would not have affected the outcome.

RT4159

Circumstances of the death

On 7/2/13 at 10.06pm Silvia Eileen Taylor activated her care alarm at her home address resulting in an immediate response from the Emergency Response Officer. Mrs Taylor complained of stomach pains and requested a Thamesdoc. The family was contacted soon after and informed that a GP was to attend within 25 minutes. Subsequently Thamesdoc doctors made several unsuccessful attempts to contact Mrs Taylor by phone at her home address. Upon the arrival of the Thamesdoc doctor at her home address at 2.30am her lack of response prompted him to contact the family to request a key to the premises. The family found upon arrival that they could not enter via the front door with the key since it had been bolted internally. The GP left to attend an emergency call after discussing matters with the family. Subsequently the police were called and entry was forced at 4am when Mrs Taylor was found to have died on her bed.

Copies sent to

Chief Coroner Signed: Martin FlemingDATED this 16‐Jul‐2014

Inquest conclusion

On 8/2/13, Silvia Eileen Taylor was found to have died at her home address of ischaemic heart disease. She had earlier activated her emergency pendant for the attendance of the doctor, although several subsequent attempts by the doctors to contact her by telephone were unsuccessful. It is found more likely than not, that earlier medical intervention would not have affected the outcome.

RT4159

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Report details

Reference: 2014-0327
Date of report: 16 July 2014
Coroner: Martin Fleming
Coroner area: Surrey

Responses identified

Responses identified 1 of 3

2 responses not yet linked

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 10 Sep 2014 (estimated).

Sent to

Bracknell Forest Council

Harmoni South East

Woking Borough Council

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.