Doris Phoebe Miller

taken: : _
1) Mrs Miller's notes and records were unavailable to the GP surgery at Broughton Gate despite having been transferred to the surgery, following the closure of the Willen practice in April 2013. Indeed was informed by a GP who gave evidence before me that she was still, in November 2013, unable to access the patient records. Over 2000 patients were transferred to Broughton Gate and if the circumstance above continues there is a possibility that lives will be put at risk: (2) On the 23rd July 2013 the GP had requested the district nurses to attend Mrs Miller to carry out an urgent blood test: The GP was dismayed to discover a week later that the blood sample had not been taken and that the results, therefore, were not available to her: There appears to be no system for effective communication between the GP surgery and the district nurses. Again this gives rise to a concern that lives may be at risk City

(3) During the inquest hearing it became apparent that the surgery at Broughton Gate did not have access to a pulse oximeter to measure Mrs Miller's oxygenation. This is relatively inexpensive item and should perhaps be available in every doctor's surgery throughout the country: In my opinion action should be taken to prevent future deaths and believe you have the power to take such action You are under a duty to respond to this report within 56 days of the date of this report; namely by January 2014. I, the coroner, may extend the period_ Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed_ have sent a copy of my report to the Chief Coroner and to the family as properly Interested Persons_ have also sent a copy to Care Quality Commission who may find it useful or of interest, am also under a duty to send the Chief Coroner a copy of your response_ The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest: You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. await hearing from you with your response_ Yours sincerely {luu Tom Osborne Her Majesty' $ Senior Coroner for Milton Keynes This report is sent to: Family of Doris Miller Chief Coroner Care Quality Commission The Practice 23rd being