Investigation Report into the NHS Care provided to the late Daniel Benfield in June 2016

Publication and distribution of a learning update arising from this case to all clinicians in urgent and emergency care covering: • SAH not presenting as thunderclap headache • Need for high level of diagnostic suspicion in any patient presenting with acute headache, especially if there is no previous history of headaches, and where headache is not responding to usual self-care. • The role of cognitive biases in diagnostic error • The importance of good record keeping both as a means of enabling better continuity of care, and as a core requirement of Good Medical Practice, GMC 2013 • The three strikes principle, and its application across the urgent care system • Safety netting should include open discussion and sharing of diagnostic uncertainty with patients.

The Trust 5 clinical IT system is modified to enable face to face as a default response after two previous contacts for the same condition, which has to be consciously over-ruled by the assessing clinician.

The interface between NHS 111 and Trust 5 should be improved to ensure that clinical information is more effectively shared between the two organisations.

The urgent care system as a whole should explore ways to ensure that when patients present to different organisations, information is more effectively shared.

NHS 111 should review their diagnostic software to ensure it is sufficiently robust to detect atypical presentations of medical conditions.