Source · Prevention of Future Deaths

Dorothy Townley

Ref: 2013-0219 Date: 28 Aug 2013 Coroner: Joanne Kearsley Area: Manchester (South) Responses identified: 1 / 2 View PDF

Significant communication breakdowns between District Nurses and the GP, inadequate burns treatment knowledge and training, and unclear procedures for urgent blood tests compromised patient care.

Date 28 Aug 2013
56-day deadline 23 Oct 2013 est.
Responses identified 1 of 2
Community health care and emergency services related deaths

Coroner's concerns

AI summary
Significant communication breakdowns between District Nurses and the GP, inadequate burns treatment knowledge and training, and unclear procedures for urgent blood tests compromised patient care.
View full coroner's concerns
_ There was a lack of direct communication between the District Nurses and the GP as to exactly what the deceased's condition was and what was required on visits_ There was no consideration given to carrying out joint visits, no communication as to how Mrs Townley's wound could be examined if there were no dressings available There was lack of knowledge within the District Nursing Team around the treatment of burns: 3, The wound assessment chart did not assist as it was not as detailed as it should be for burns in order to help chart their progress or deterioration: There was a lack of training for District Nurses on the treatment of burns.
5. There was a lack of understanding between the GP and District Nurses as to how to request urgent blood tests: It was assumed by the GP that his request for a blood test would be treated as urgent done that day (on 10"h); the the day being from and

District Nurses indicated it would only be carried out as 'urgent' if requested.

Responses

1 respondent
Royal College of General Practitioners Other
29 Oct 2013 PDF
Noted

The Royal College of General Practitioners provides context on its role, training, and advice to members, highlighting relevant sections of the GP Curriculum related to communication between professionals and patient safety. (AI summary)

View full response
Dear Ms Kearsley Rule 43 Coroners Rules report Dorothy_Townley (deceased) Thank you for your letter addressed to the College's Chief Executive which has been passed to me for response as Honorary Secretary: On behalf of the College, give below our comments on the inquest report: The_role of_the College The Royal College of General Practitioners is a registered charity under Royal Charter and is the largest membership organisation in the United Kingdom solely for GPs. Founded in 1952, it has over 44,000 members who are committed to improving patient care, developing their own skills and promoting general practice as a discipline. We are an independent professional body with enormous expertise in patient-centred generalist clinical care: Through our General Practice Foundation; established by the RCGP in 2009, we also maintain close links with other professionals working in General Practice, such as practice managers, practice nurses and physician assistants As well as running the postgraduate Membership examination (MRCGP) which is now required for doctors to qualify as GPs, the College also provides continuing professional development (CPD) for its members, and these continuing programmes are also available to non-members of the College: However; not all GPs are members of the College, and older GPs may never have joined. The General Medical Council holds the register of all who are considered able to practise as GPs, and it is to the GMC that revalidated doctors will be notified, Similarly, it is not for us to comment on the performance of any individual GP and the information set out below is solely to show you what we do in the context of training and advice to our Members. As a general observation; it would seem that the GP looking after Mrs Townley was obviously concerned about his patient and was conscientious about carrying out home visits, including making an unscheduled visit to Mrs Townley to see her and to check that the specified blood test had been carried out: However, would agree with the concerns listed about the management of the actual burn injury and the wound assessment chart by the District Nursing staff. Royal College of General Practitioners 30 Euston Square London NW1 2FB Tel 020 3188 7400 Fax 020 3188 7401 Email info@rcgp.org.uk Web WWW.rcgp.org uk Patron: His Royal Highness the Duke of Edinburgh Registered charity number 223106 stock 2813

From the perspective of general practice , would comment that the College can influence the training of general practitioners through the guidelines for best practice it sets out in the College's GP Curriculum: (The curriculum forms the foundation for GP training and assessment across the UK, prior to taking the College's Membership Examination (MRCGP) and is relevant to GPs throughout their career; including preparation for revalidation) http:Il rcgp orguklgp-training-and-examslgp-curriculum-overview aspx In this case; there are issues about communications between professionals and the following sections of the GP Curriculum are of particular relevance in the case of the care of Mrs Townley: "Being GP "As a GP you should:
1.4.2 Understand the processes of referral into secondary care and other care pathways
1.4.3 Manage the interface between primary and secondary care, including unscheduled care and communication with other professionals" "Patient Safety and Quality of Care "As a GP you should
4.2 Reflect on the risks to patient safety in a care pathway in which a variety of healthcare professionals are involved, looking at interface issues and be able to comment on the ways in which, as a GP, you can work to minimise these "The GP in the Wider Professional Environment "As a GP you should
1.2.3 Work effectively with the full range of primary care services, and across the primary-secondary care interface for the benefit of patients. Additionally, the case highlights the need for general practitioners to systematically audit their work and to carry out significant event analysis where appropriate. The SEA is a standard method employed in GP appraisal process The document Good Medical Practice for GPs (RCGP , 2008) sets out the principles underpinning the revalidation and appraisal process. http Ilwww rcgp org uklrevalidation-and-cpdl~Imedia/Files/Revalidation-and: CPDICPD%2OCredits%20and%2OAppraisalGoodMedicalPracticeforGPsJuly208ashxashx hope you find these comments helpful:

Report sections

Investigation and inquest
On the 24th October 2012 ! commenced an investigation into the death of Dorothy Townley, 94 years of age. The investigation concluded at the end of the Inquest on 2Oth August 2013. The conclusion of the Inquest was that the deceased died as a result of an accidental death.
Circumstances of the death
On the September 2012 at her home address the deceased had spilt a cup of sustaining burns which developed and became infected. There were missed opportunities to consider earlier hospital intervention. On the 1th October 2012 she was admitted to hospital but despite active treatment her condition deteriorated and she died on the 20"h October 2012 Having spilt her tea on the 28"h September she was washed and changed by her carer who was present. The next area on her chest looked a little red, however by the 30"h blisters had developed and the carer called the District Nurses_ District Nurses attended that and applied dressings to the blistered area which by this stage had burst. She was then seen the following when a prescription for further dressings was written and she was listed for visits every 2 days_ On the 3r October the dressings had not been delivered and by this stage her chest and left breast area were from blistered areas and looked sore She was changed to visits. On the October more skin was noted and a GP visit was requested as it was felt that the site was infected. Her GP visited the following on the 5th October This was not a joint visit, In evidence the GP indicated he had received a request to visit Mrs Townley: He did not examine her chest as this would have meant taking the dressing off her and it was his belief that there were no replacement dressings available in the property. He looked and could see the superficial wounds on the outer edges which "Iooked to be healing ok" He did not prescribe atibiotics as he felt they were not required; he did prescribe Flamazine cream. He indicated in evidence that to a large extent; in relation to wound care, GPs are led by the nurses: The District Nurses continue to visit On the 6th October are concerned about her condition. Her wound and condition continue to deteriorate On the 10th October the District Nurses request a further GP visit: The GP re-attends; again this is not a joint visit Her_dressing_is_not_removed_and antibiotics_are_not_prescribed He_notes the the 28th tea, day the two day day exuding daily loss day they deterioration in her condition, that she had visibly deteriorated, was very dehydrated and not keeping much down: However he stated that he did not think this was related to her wound_ In evidence the GP indicated that he planned to take a blood test from Mrs Townley, he could not do this at the time of his visit on the 10" as he did not have equipment to do so although he felt that a blood test was required urgently. There was then some confusion in the evidence as to what happened but it appears that on return to the GP practice on the 10th a request was made t0 the District Nurses to take a blood test from Mrs Townley This was not marked as urgent: On the 11th October the GP re-attended Mrs Townley's address on the chance he would see her ad take the blood test (it was not known by him whether in fact the District Nurses would have already done this ) As this was an unscheduled visit Mrs Townley was on her own in the property and was too poorly to be able t0 open the door: He left the property and as he was aware that the District Nurses would be calling later that did not do anything further. When the District Nurses attended on the 11th they called the Out of Hours Doctor who immediately admitted Mrs Townley to hospital: She was transferred immediately to the Specialist Burns Unit at Wythenshawe Hospital, who immediately raised a safeguarding alert with regards to her condition. It was recorded that she had 5-6% second degree burns covering most of her upper chest These were infected; she was very dehydrated and had atrial fibrillation: The Consultant who gave evidence at the Inquest confirmed that in a 94 year old lady with frail skin this was a significant burn which had developed; he would have expected her to be referred to them much sooner: Despite all active treatment Mrs Townley died on the 20" October. During the Inquest heard evidence from the Clinical Lead for District Nursing who indicated that at the time of this incident there was nothing in place within the District Nursing Service to help them deal specifically with burns. The Wound Assessment Chart used was not suitable for recording burns. There was no consideration of referral or input requested the OUTREACH service at the Specialist Burns Unit (a service in place at the time where specialist trained nurses can offer advice to community nursesldoctors on the management of burns):
Action should be taken
In my opinion action should be taken to prevent future deaths and believe your organisation has the power t0 take such action.

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Report details

Reference
2013-0219
Date of report
28 August 2013
Coroner
Joanne Kearsley
Coroner area
Manchester (South)

Responses identified

Responses identified 1 of 2
All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 23 Oct 2013 (estimated).

Sent to

Royal College of General Practitioners
Royal College of Nursing

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