Coroners on our case

Copperfield reflects on a recent inquest and asks whether the wrong lessons are being learned about GPs’ role in emergency referrals

A few years ago my son developed classic appendicitis symptoms. I diagnosed him by phone – it was that obvious. Even he knew the difference between a dodgy kebab and a surgical emergency. My wife then called me to say the ‘paramedic’s ultrasound’ suggested it was just gastroenteritis. I gave her a message to pass back to them which she did, just deleting the expletives. He perfed that evening but was already in hospital by then, and so lived to tell the tale.

Which is why the horrible and sad story about a poor child similarly misdiagnosed in A&E who wasn’t so lucky really resonates.

Our thoughts, obviously, are with the family. But with the GP also, as the coroner’s comments sound obliquely critical, despite a correct primary care diagnosis. Obviously, we don’t know all the nuances of the case. But those comments have implications for all of us and so warrant scrutiny. In order:

1. No ambulance was summoned. No surprise there. There’s the wait for a reply, the endless interrogation and the no-NEWS-score shaming. And anyway, the ambulance takes the scenic route as soon as they hear the patient is with the GP – hence me left recently with a query MI for an hour, at which point I told his elderly mum the least bad option was for her to drive him to A&E.

2. No letter. OK, in an ideal world, the niceties are, well, nice. But sometimes a letter isn’t needed, feasible or appropriate. Besides, when was the last time anyone in secondary care took any notice of anything you wrote? The patient or carer is perfectly capable of explaining they’ve been sent up after GP assessment – the problem is whether anyone listens.

3. Lack of GP awareness of triage and assessment in local hospitals. Why would we understand the intricacies of a system of their own making which is not communicated to us, or has changed anyway by the time it is? Also, when you do try to negotiate the correct pathway, the on-call team – if it ever answers – inevitably diverts you elsewhere. Usually, ironically, to A&E.

So I don’t buy the assumption that a letter or an ambulance is a proxy for severity, which therefore implicates the GP. Similarly, the absence of a letter or ambulance shouldn’t downgrade the case: very sick patients may pitch up themselves, give up waiting for an ambulance or be sent in via a phone call. Issues around how patients present, with what paperwork, and how that affects triage are just noise, drowning out the real issue – which is that any acutely ill patient merits a proper assessment from suitably qualified and experienced staff.

We shouldn’t draw too many conclusions from just one case. But my experience, and that of my colleagues, suggests that the journey of the acutely ill is fraught with peril once they leave their home or the GP surgery. This is what requires scrutiny. We have our own theories about what might be going wrong. Oh, and I can put them in a letter if that helps.

Dr Tony Copperfield is a GP in Essex