Peter Unsworth
The coroner's concerns
1. miscommunication of complex medical advice
“The advice provided by the Consultant [name redacted] related to a very complex medical situation. It was not recorded in writing. The Consultant [name redacted] surgeon did not record it in the patient's records nor email his understanding of the advice to the Consultant [name redacted] for confirmation of what he understood the advice to be.”
2. lack of written confirmation of advice
“The Consultant [name redacted] did not confirm her advice in writing or make any record of the advice given”
3. potential misunderstanding of advice importance
“As a consequence, there may have been a misunderstanding of the basis on which the advice was sought and/or given, and of the import of the advice”
Responses
2020-0267-Further-response-from-GMC-Redacted.pdf ↗· Royal College of Physicians
Stated action · around three months
“We will attempt to complete our initial review into the actions of Dr in around three months”
2020-0267-Response-from-Ashford-and-St.-Peters-Hospitals-REDACTED.pdf ↗· Royal College of Physicians
Stated action · December 2021
“The Trust notes that the report has been sent to the national bodies and will embrace any changes recommended by them.”
2020-0267-Response-from-British-Orthopaedic-Association-Redacted.pdf ↗· NHS England
Stated action
“The BOA will be taking this further. We produce BOAST documents (British Orthopaedic Association Standards) and will be setting up a short life working group involving haematology colleagues to see if it would be possible to produce relevant guidance on the management of such cases in the future.”
2020-0267-Response-from-GMC-Redacted.pdf ↗· General Medical Council and St. Peter's Hospital
Stated action
“We will consider the information you have provided and determine whether any further action is required either through our Outreach or fitness to practise process.”
2020-0267-Response-from-Royal-College-of-Physicians-Redacted.pdf ↗· Royal College of Physicians
Stated action
“Following a review with PRSB the recording of advice is covered by GMC guidance, however standards to confirm the accuracy of that advice if it is given verbally is not currently covered in any standard. We have highlighted this as a member of PRSB. In response to learning from the CoViD 19 pandemic and the increase in the use of remote advice have proposed that standards are developed with respect to what elements of remote advice should be documented to ensure effectiveness and prevent harm.”
Response-from-RCS-England-2020-0267-Redacted.pdf ↗· NHS England