Clare Cooper
25 Jul 2014 · Coroner Karen Henderson · Surrey
The coroner's concerns
1. assumption of psychiatric cause without ruling out organic disease
“Lack of evidence of a robust assessment of presenting signs and symptoms with a presumption of a psychological/psychiatric problem without considering or excluding an organic cause”
2. omission of vital sign monitoring for weight loss
“Lack of GP routine vital sign monitoring e.g. heart rate, blood pressure and weight measurement when weight loss is a concern with a lost opportunity to assess the severity of weight loss”
3. absence of electrolyte abnormality detection system
“No established system for recognition, assessment and management of electrolyte abnormalities within the GP practice and/or consideration of the chemical pathology service to 'flag-up' particularly concerning results”
4. inadequate knowledge of hyponatraemia thresholds and investigations
“Lack of understanding of the underlying causes of hyponatraemia (consistently or intermittently low) and the level below which will require further investigation, and the investigations that should be carried out, particularly in circumstances when there is no obvious cause of the low sodium”
5. inadequate referral communication to eating disorder service
“Insufficiently detailed referral letter to EDS (mentioning 'low sodium' but not accompanied with a copy of the blood results) and an opportunity was lost for its significance to be considered”
Responses
2014-0345-Response-by-Royal-College-of-General-Practitioners.pdf ↗· Royal College of Physicians
Stated action
“The College believes that sound recording systems and well organised record-systems are fundamental to good general practice and communications with fellow healthcare professionals outside the practice. This expectation is set out in the section of the GP [name redacted] on”
2014-0345-Response-by-Royal-College-of-Psychiatrist.pdf ↗· Royal College of Psychiatry
2014-0345-Response-by-Surrey-Borders-Partnership-NHS.pdf ↗· East Surrey Clinical Commissioning Group
Stated action
“We have revised our referral form in order to try and improve the quality of information that GPs provide when referring patients. The form asks for more detail from the GP including that they consider and exclude organic causes of weight loss prior to making a referral to the Eating Disorders Service.”
2014-0345-Response-by-Woodlands-Surgery.pdf ↗· Woodlands Surgery