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New mothers recorded as ‘having died of cot death’ following coding error

NHS England has written to all GP practices in Essex, advising them of a coding error that is placing an RIP gravestone template on some new mothers’ medical records.

The email to practice managers says that the template incorrectly codes ‘Safe Sleep discussed to reduce the risk of sudden infant death syndrome (SIDs) with explanation’ as a cot death.

This 'in turn puts the RIP gravestone template on the mother’s medical record advising that she has died from a cot death’, the email adds.

The coding error was found in the Virgin Care ‘Maternal and Early Childhood Sustained Home Visiting programme (MECSH)/Postnatal’ template.

Dr Sarah Robinson, patient experience and quality manager, Nursing Directorate, said in the email: ‘Obviously this has implications for patient experience and the potential to cause distress to new families.’

Dr Robinson said that the error had been escalated to Virgin Care but asks practice managers to ensure that all staff are aware of this coding error.

A Virgin Care spokesperson said: ’With the creation of the new Essex Child and Family Wellbeing Service a number of new templates were required for the clinical system.

’A template coding error relating to cot death was identified and has now been fixed; with all other data entry templates checked for accuracy. At the time, every child’s electronic narrative record clearly indicated they were alive and well. A review is also underway to ensure that any recorded issues are corrected.’

Readers' comments (1)

  • Who has been using the Template, and in which organisations?
    If this is a TPP template, then only the organisation making the entry will be able to correct the error - so correction may be a major problem.

    Does the coding of the mothers as having died trigger any other actions e.g. removal from the practice list, any call/recall registers - or be reported to DWP or HMRC?

    With integrated records and massive data sharing, this Coding incompetence could have major repercussions!

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