John Spencer
19 May 2025 · Coroner Edward Steele · East Riding of Yorkshire and City of Kingston Upon Hull
This report repeats 1 earlier warning. See the linked reports.
The coroner's concerns
1. lack of access to GP medical history
“The GP medical history summary, populated by the GP that a patient is registered to, is not always accessible to a GP out of hours surgery. Evidence was given that there are various reasons for this, including the patient not providing consent for the exchange of this information. However, on some occasions, even when a patient has consented, the patient record systems utilised by the GP registered practice and the GP out of hours surgery, insofar as being different computer systems or for whatever other technological reason, prevented the exchange of information into the GP out of hours surgery. In this case, evidence was heard that the GP practice was using the EMIS system and that the urgent treatment centre (GP out of hours surgery) was using SystmOne. That fact caused the GP out of hours surgery to not be able to access Mr [name redacted] GP medical summary. This situation generates a concern that, providing the patient has consented, key medical information may not be conveyed to the GP out of hours surgery which should be accessible to allow the appropriate exchange of medical information to inform what examinations should take place in an out of hours setting. This concern is particularly significant in circumstances where the patient does not say and/or present with the points in the medical history relevant to the GPs determination about what further examinations should occur flowing from the medical history of the patient.”
2. purulent peritonitis secondary to bowel perforation
“The post-mortem examination report stated that, in the opinion of the Consultant [name redacted], Mr [name redacted] died due to a purulent peritonitis (inflammation of the abdominal cavity) secondary to a bowel perforation (rupture).”
3. right inguinal hernia
“In 2010, some 13 and a half years earlier, Mr [name redacted] had suffered from a right inguinal hernia. This was recorded in his GP medical history. The GP medical history was not available to the GP out of hours surgery.”
Linked reports
Closely relatedConfidence 0.80 · moderate
Earlier report
“it is either not possible to access information held by a GP practice out of GP surgery hours or where it is possible to do so that is only available if the GP is in the same geographic area as the accident and emergency department.”
This report
“The GP medical history summary, populated by the GP that a patient is registered to, is not always accessible to a GP out of hours surgery.”