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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.


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