Kai Takagi
27 Oct 2023 · Coroner Paul Rogers · Inner West London
The coroner's concerns
1. missed urgent follow-up care
“Patients that leave the hospital Accident and Emergency Department with outstanding blood results or other diagnostic tests are not followed up and "tracked" in the same way that in-patients are”
2. risk that patients will not be called back for urgent follow-up assessment or treatment
“That as reliance on Accident and Emergency departments for routine out of hours health care increases, the burden of call back also increases on hospitals for patients who have left at a time when their departments are already over-stretched in dealing with admissions and those presenting to the department”
3. risk of unverified call back action
“That the system remains heavily dependent on oral handover, which is not amenable to independent audit as it assumes a person has done what was asked of them”
4. risk that patients who have left with potentially life-threatening conditions may not be contacted urgently
“That a periodic clinician led review of all abnormal blood results (and other test results), which the hospital has explored since I raised the matter in the hearing has not”
Responses
2023-0502-Response-from-NHS-England.pdf ↗· NHS England
Stated action · March 2016
“Both NHS England and the Royal Colleges have published national guidance and standards for following up on test results following discharge from hospital, please see below: (cid:120) NHS England, supported by the Academy of Medical Royal Colleges (AoMRC) published the Standards for the communication of patient diagnostic test results on discharge from hospital in March 2016. One of the guiding principles is that the clinician who orders the test is responsible for reviewing, acting and communi”