Coroner makes recommendations to improve patient safety
CORONER MAKES RECOMMENDATIONS TO IMPROVE PATIENT SAFETY
In a statement released by her Freeth Cartwright’s clinical negligence specialist solicitor Paul Balen after the inquest into the death of her husband Dennis Aucote, his widow Marta Aucote (54) said:
“I firmly believe that my husband died due to a chain of events where the correct procedures and checks were NOT carried out. Had they been my husband would still be with us today. I would urge anyone with allergies to request that their medical records are checked to ensure that those allergies have been flagged on their medical records especially when they have been computerized.I hope that this inquest will result in robust measures being put into place in order to ensure that this type of tragic mistake does not re-occur in the future.I would like to give my utmost thanks to Detective Sergeant Richard Burton and Detective Constable Sue Sallis who have been a great support to me since Dennis’ death.”Background
1. Dennis Aucote, 57, a forklift engineer of Newhall near Swadlincote in Derbyshire, died in March 2008 after suffering an anaphylactic reaction after taking one tablet of ibuprofen. Mr Aucote had a history of asthma and severe allergic reaction to some fruit and painkillers.
2. In March 2008 he hurt his shoulder and made an appointment to see Dr Hignett at Newhall Surgery, Swadlincote, Derbyshire.
3. During a 3 day hearing Derby Coroner’s Court heard evidence that staff at Newhall Surgery had mixed up Mr Aucote’s notes with those of a similarly named patient Dennis Allcote.
4. The computer system used by the surgery involved a receptionist typing in three letter of the surname and three of the Christian name. One explanation was that the receptionist whose identity could not be ascertained because the surgery at the time allowed any receptionist to use a computer once logged on typed in ALL instead of AUC. Tests showed that this only produced one patient’s name. The receptionist then must have failed to check the patient’s address and date of birth. Witnesses including a receptionist and Dr Hignett told the court they were unable to explain how the mix-up with the two men’s notes happened.
5. However, the inquest was also told that even if the GP had had the correct patient’s records on his computer screen Mr Aucote’s allergy to certain painkillers had not been properly recorded on his own computerized notes when they had been transferred from the old style Lloyd George card system.
6. The error was compounded in the 3 minute consultation when the GP, Dr Andrew Hignett failed to ask Mr Aucote about any allergies before prescribing ibuprofen and did not explain to the patient that ibuprofen was a NSAID which the patient would have known he should not take.
7. The court was told that Dr Hignett was looking at Mr Allcote’s medical notes when he prescribed ibuprofen to Mr Aucote, and the prescription contained Mr Allcote’s name.
8. Further failures at Newhall Pharmacy allowed Mr Aucote to collect the ibuprofen even though the prescription showed Mr Allcote’s name and address. The counter assistant with 29 years experience confirmed to the inquest that whilst she could not recall the patient she would have followed the then system of calling out the patient’s name and first line of address and filled in the back of the prescription as the address had not been changed by the customer.
9. The inquest heard that GP practices run by GP principals and pharmacies were left to devise their own protocols and that there was then and currently no national protocol for the identification of patients in GP surgeries or pharmacies. Even though had its existing policy been followed the error would not have occurred within 48 hours the Newhall surgery had devised a new protocol involving the use of the date of birth as the principal identifier with the patient asked for details of that and name and address rather than simply being asked to confirm name and address. The pharmacy had also immediately changed its patient identification policy.
10. Expert immunologist Dr Richard Pumphrey who had maintained a register of all fatal anaphylactic reactions occurring in the UK since 1992 gave evidence that the cause of death was anaphylactic asphyxia from taking the one tablet of ibuprofen.
11. Witnesses expressed the view that date of birth should be the primary patient identifier and that patients should be asked to identify themselves not have their details read out to them.
12. Mr Aucote who had been married for 22 years left his widow, Marta, and two children now aged 23 and 19.
13. At the conclusion of the inquest the Derbyshire Coroner Dr Robert Hunter entered a narrative verdict and indicated that he would be making recommendations to appropriate authorities.
COMMENTS FROM PAUL BALEN the Aucote family’s solicitor:
If anyone of the checks and balances that should have been in place had been observed the mistake of identity should not have happened.
There are apparently no reliable national statistics for the incidents of patient identification errors but my clients feel that it is essential that the authorities take urgent action now on a national basis to ensure that best practice is adopted in GP’s surgeries and pharmacies throughout the country.
My clients fervently hope that this kind of error will not be repeated in the future and that lessons can be learnt from Mr. Aucote’s tragic death.
Possible learning points:
1. There should be national patient identification protocols and surgeries and pharmacies should be audited for compliance and for training of staff.
2. There should be a national record of, and reporting requirement for, actual and near miss patient identity errors in GP’s surgeries and pharmacies and the reasons for the errors analysed and reported to the professions.
3. The date of birth should routinely be the first element of patient identifier and all identification strategies should involve active not passive identification by the patient.
4. The reverse signature part of the standard prescription form should be reviewed to require the patient (if it is the patient collecting the medication) to enter his date of birth and the current ambiguous wording relating to name and address should be revised. It may be better to separate the section to be completed by the patient from the section to be completed by someone collecting a prescription on his behalf.
5. There should be a review to ensure that GP and pharmacy computer systems are compatible.
6. Concern was raised by the GP concerned that his surgery’s latest computer system did not automatically flag a patient’s allergies. If this is the case GP computer systems should only be approved if they do.
ends - 15 January 2010