Percy Jacks
27 Jul 2017 · Coroner Andrew Barkley · South Wales Central
The coroner's concerns
1. inadequate DVT scan result communication to GP
“The investigation revealed that the system for the Bronglais Hospital contacting the GP was poor. The result of the DVT scan which took place on 6 February was sent to the incorrect GP surgery and despite an investigation as to why that happened no satisfactory explanation could be found. The system within the GP surgery for prescribing Rivaroxaban was poor and relied solely on receiving the notification of the results of the scan from the hospital. There was no facility to review the medication”
2. inadequate DVT management coordination between hospital and GP
“The evidence revealed a view from one of the hospital doctors to the effect that DVT management should be undertaken within the hospital setting rather than by the GP's to ensure that a comprehensive and failsafe system operated rather than the somewhat haphazard one revealed by the evidence”
3. fragile communication across GP, hospital, and care home for patient moving between care homes
“Overall the evidence revealed a very fragile system of communication between GP hospital and care home in circumstances in which the deceased had moved between three care homes in a short period of time”
4. inadequate GP medication review after DVT diagnosis
“The system within the GP surgery for prescribing Rivaroxaban was poor and relied solely on receiving the notification of the results of the scan from the hospital. There was no facility to review the medication to ensure that the correct dosage for the correct period of time continued to be prescribed”
5. inappropriate medication and plan transfer via patient transport
“The evidence further revealed a practice of sending details of the medication and clinical plan back with the driver of the patient who had taken the patient back from hospital to the care home”
Responses
2017-0329-Response-by-Care-Quality-Commission.pdf ↗· Care Quality Commission
Stated action
“We propose to respond to each of them in turn for ease of reference.”
2017-0329-Response-by-Rhayader-Group-Practic.pdf ↗· Welsh Government
Stated action
“Allreferrals for suspected DVT are recorded by the Administrative Team at the practice and followed up 48 hours later to ensure the results have been received”
2017-0329-Response-by-Welsh-Government.pdf ↗· Welsh Government
Stated action
“HIW is currently undertaking a review of discharge arrangements focusing on communication and the quality of documentation used to support patient discharge from secondary to primary healthcare.”
2017-0329-Response.pdf ↗· Welsh Government
Stated action
“The process of managing potential DVT patients has been streamlined and a definite pathway introduced. All GP referrals which suspected DVTs are referred direct to the Hospital's Radiology Department as per the attached protocol. It is incumbent on the GPs to commence therapy prior to an ultrasound scan being undertaken. Following their scan, if the result is positive, the patient is referred back to the A & E Department where they are reviewed by the on-call Physicians. There is a pre-printed letter”