Viola Burke
20 May 2015 · Coroner Jacqueline Devonish · London Inner (North)
The coroner's concerns
1. use of asthma pump without diagnosis
“In the absence of a diagnosis of asthma, no questions had been asked about the reason for the use of the asthma pump, and it's use became a significant diagnostic tool for the GP Out of Hours Service.”
2. lack of care plan for vulnerable patient
“The GP practice had implemented a system for care plans to be held by identified vulnerable patients to ensure that the Out of Hours Service had full access to the medical records so as to avoid unnecessary hospital admission.”
3. failure to engage patient with care plan invitation
“Evidence was given at the inquest that [the deceased] had been sent an invitation letter on 1 October 2014 to attend the surgery for the care plan. When [the deceased] did not respond the GP receptionist is reported to have made three unanswered telephone calls to [the deceased]'s landline number.”
4. care plan not discussed during visits
“The GP consultation record produced at inquest stated 'Admission avoidance care ended'. The records also showed that [the deceased] attended the surgery with her son on 5 October, and on two further occasions during October on the 11th and 21st. Her daughter is also seen to have telephoned on the 30th.”
5. inadequate care plan system implementation
“Evidence was given at inquest that the 'Care Plan system' was a Hackney wide initiative implemented in August 2014 by CHUHSE in collaboration with GP practices. The scheme was still in its infancy. The intention was to ensure that the London Ambulance Service and Out of Hours Services would have full access to the patient records of the most vulnerable upon agreement of the patient.”
6. lack of record access for out-of-hours doctors
“Questions were also raised about how the care plan would be kept up to date, and whether the London Ambulance Service would have computerised access to records. Doctors attending Out of Hours operate in a medical vacuum, acting on findings in that moment without access to previous medical history, blood and blood pressure test results.”