Constance Connolly
22 Jun 2017 · Coroner Andrew Harris · London Inner (South)
The coroner's concerns
1. discharge from A&E without follow up
“discharge from A&E department, giving rise to concern that in my opinion that there is still a risk that future deaths will occur unless action is taken”
2. lack of follow up on ordered scan
“The doctor who ordered the scan did not conduct any follow up to see that it had been performed”
3. miscommunication of care responsibilities
“The referring doctor notified the GSTT community palliative care team of the need to organize a MRI scan, on the understanding that the team was taking over care”
4. incomplete discharge documentation
“The discharge note to the GP from the A&E indicated a diagnosis of stroke (presumed before CT scan), did not mention the CT finding of cerebral lesions that may be metastases, nor the need for EMI scan and further investigation to conform diagnosis, nor the booking of a MRI scan”
5. appointment cancellation due to outpatient status
“A member of the palliative care team rang the AWE department and was told that the scan appointment was the next day (17th). When the patient and her mother attended the next day, she was told that there was no appointment”
Responses
2017-0201-Response-by-Kings-College-Hospital.pdf ↗· Kings College Hospital
Stated action
“The Trust agrees follow-up of patients in terms of proposed investigations is the responsibility of the team who has ordered the investigation(s). An outpatient MRI scan appointment was made, but this should have been communicated more clearly to the GP. The "virtual review', as described below under Matter 2, should facilitate clearer communication to health care colleagues, patients and families.”
2017-0201-Response-by-The-Royal-College-of-Emergency-Medicine.pdf ↗· Kings College Hospital
Stated action · September 2017
“we are preparing a safety alert for September 2017, reminding Members and Fellows to ensure follow up arrangements are adequate for patients discharged from the emergency department.”