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A faulty production line

Coroner calls for changes to discharge letter procedures after patient death

A coroner has called for discharge letters to be sent to all medical attendants, including GPs, following the death of a patient.

In a prevention of future deaths report, senior coroner in Liverpool Andre Rebello outlined that better patient care could be delivered in the future if discharge letters were not just sent to GPs, but to ‘all current medical attendants’ in the primary, secondary and tertiary sector.

It comes after Lewis Doyle died in January from organising pneumonia, traumatic injuries to the feet, severe coronary artery disease and metastatic carcinoma of the prostate.

Mr Doyle, who was 80-years-old, also had a medical history of Parkinson’s disease, cerebral meningioma and a recurrent depressive illness (without psychosis) for which he was prescribed lithium.

The BMA said while it could not comment on the specifics of the case reviewed by the coroner, health information should be sent to all clinicians involved in the care of a patient - and stressed the need for better IT to ensure this can happen.

On 10 September 2018, Mr Doyle was admitted to Arrowe Park Hospital because of an episode of acute coronary syndrome. His lithium medication was suspended and on 20 September 2018, the lithium was stopped due to the toxic level but later he suffered a cardiac arrest.

Mr Doyle was discharged from Liverpool Heart and Chest Hospital four days later following a procedure fitting an internal cardiac defibrillator and coronary artery stents.

He visited his GP due to his enlarged prostate on 22 October 2018 and later that day he fell in front of a train, to which the coroner stated the possibility that Mr Doyle was experiencing psychosis. Mr Doyle then underwent a bilateral foot amputation at University Hospital Aintree due to his limb injuries.

On 30 October 2018, lithium was re-introduced after a discussion between a Merseycare psychiatrist and University Hospital Aintree cardiologist, who said there were no alternatives for mood stabilisation which ‘did not carry a risk to his cardiac health’.

Mr Doyle was transferred to the orthopedic ward at Arrowe Park Hospital on 17 November 2018 but developed a chest infection that deteriorated until 8 January 2019, when a decision was made to turn off the internal cardiac defibrillator. He passed away that day.

Summarising his concerns, the coroner said the lithium was stopped because of the toxic level and the effect on alternative medicine on Mr Doyle’s cardiac health. However, the coroner evaluated the need for information regarding suspended or stopped medication by the original prescribers.

BMA GP committee chair Dr Richard Vautrey said: 'We expect clinical information to be sent, where relevant, to other clinicians as well as GPs, and in most cases, this happens.

'Crucially, we need better, fully-funded IT, that allows all doctors involved in a patient’s care to access up-to-date clinical information on a common electronic record.'

However, Kent LMC Dr John Allingham said sending discharge letters to other medical attendants such as a community mental health team in this case ‘would not necessarily’ have helped.

He said: ‘In this case the specialists i.e. psychiatrists responsible for his mental health may have had an interest in the mood stabiliser and ensuring the best treatment.

‘In my opinion, this should have been addressed whilst he was an in-patient and picked up by the community mental health team at follow up. This would not necessarily occur by copying the discharge summary to the mental health team.’

He also added that copying multiple parties into discharge summaries would increase the risk of breaches to confidentiality.

He said: ‘The danger if this rule 28 instruction is adopted is that the list of people to whom a discharge summary needs copying to could be extensive with risks of confidentiality breaches and confusion.’

Elsewhere in Scotland, GPs in Forth Valley were sent almost 400 incorrect discharge letters stating that patients had conditions like cancer or endometriosis following a computer glitch.

Readers' comments (6)

  • Yes more information, lots more information needed. 22 page discharge letters to trawl through telling you precisely nothing and removing time to care. Definitely no need for more clinicians with the time and common sense to actually talk to each other.

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  • The coroner is not focussing on the source of the problem re the lithium although I recognise the info given is patchy.Its a case of super-specialisation only focussing on their bit,kicking people out when scarcely patched up without having carefully read the notes which if they had, sending him back from Stents and Co back to Arrow Parke would have been wise where liaison between his original team and psychiatry to address the clearly unresolved item of his mental health medication could have been addressed. Informing the GP that lithium had been ceased would achieve noting because a GP is prevented from resuming it in any case.

    Sending more people more paperwork when the paperwork which exists already is not read properly is no answer.

    Mr Coroner- if you feel you must "do something", ponder my words.

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  • And the spineless "Ever so humble, me'Lord" BMA should have the balls and knowledge to also see what appears clear in terms of the failings.

    The head honchos of the BMA should have "RTFN" tattooed on their hands: "Read The Fuc@@ig Notes", and whilst the tattooist is at it, the junior hospital doctors and consultants too. Make it a tax-deductible expense.

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  • This sounds like an unusually complex situation: how often do we have to deal with a patient jumping in front of a train who happens to have had an unrelated cardiac arrest the previous month and who also happens to have an unrelated terminal illness and an unrelated degenerative disease?

    There is a danger that if we alter systems to better cope with this type of very rare case, the result will be increased bureaucracy when dealing with simple cases. And this increased bureaucracy will itself put other lives at risk by taking up more clinician time.

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  • GPs do this GPs do that, inform of this and that, new guidances, hoops, QoF, PCNs, child protection, CQC, GMC, CCG......
    The danger in all this is pretending to make it safer when it is actually making it more dangerous as important things gets lost as GPs are doing too many things distracting them from what actually needs doing by them, like blood tests, seeing patients, Med 3s where appropriate, monitoring medication and issuing them.

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  • DrRubbishBin

    It's a shame corners are now a major source of information for the government on how badly they are doing with the NHS. One of a number of recent articles in PULSE covering coroner comments across a wide range of clinical areas all regarding failures of administration

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