Thelma Houghton

Date of report: 16/05/2023 Ref: 2026-0438 Deceased name: Thelma Houghton Coroner name: Graeme Irvine Coroner Area: East London This report is being sent to: NHS England | Department of Health and Social care | Marylands Healthcare | Practice Plus Group REGULATION 28 REPORT TO PREVENT FUTURE DEATHS

I am Graeme Irvine, senior coroner, for the coroner area of East London

On 14 th April 2022 I commenced an investigation into the death of Mrs Thelma Houghton age 79. I opened an Inquest on the 11 th July 2022. The Inquest was heard on the 11 th April 2023. The conclusion of the inquest was a short-form conclusion, natural causes. The medical cause of death was found to be; 1.a. Small Bowel Ischaemia

1. Right Nephrectomy, Diabetes Mellitus, Left Ventricular Hypertrophy

Mrs Houghton had undergone a nephrectomy on 5th April 2022 and had been discharged from hospital. Mrs Houghton’s family had sought medical assistance for her through the NHS 111 service at 17.13 hrs on 12th April 2022, reporting that she had been experiencing  nausea, bouts of vomiting and was now unrousable. The call resulted in a paramedic visit to Mrs Houghton in the early evening. Paramedics noted that she was hypoglycaemic and provided with I/V Glucose solution. The paramedics were supported by the on-call clinical assessment service, a GP. Against  medical advice, Mrs Houghton declined to be taken to hospital. A decision was made for family to monitor Mrs Houghton at home, and for a referral to be made to her GP for follow up the next morning. The GP referral was not affected. On the morning on 13th April 2022 a further call was made by family to 111, further input was given from the on call clinical assessment unit. Advice was given for the family to  monitor the patient. Critically, the doctor providing advice did not have full knowledge of  what advice had been given by their predecessor or that a GP referral had not been  successful. On the evening of 13th April a further call was placed to 111 indicating that Mrs Houghton had deteriorated, again the patient was allocated a call back from the clinical  assessment unit within 1 hr. Due to high levels of demand that requirement was not met. At 01.35 on 14th April a courtesy call was made to Mrs Houghton’s family who, when it was suggested, agreed to resolve the matter in the morning, after the patient had had  some sleep. Early on the morning of 13th April 2022, Mrs Houghton was found unresponsive, paramedics verified her death at 05.44 hrs

During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the  circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. –

1. Delay in the provision of emergency response by the 111 service due to a chronic insufficiency of resource.
2. The absence of a facility in the III computer system to allow advisers from different organisations to review notes made by predecessors.
3. The inadequate pathway of communication between the 111 service and the patient’s GP

a.   A 111 clinical adviser did not have a functioning smart card that would allow both; review of the patient’s GP records and the ability to book specifically  reserved GP appointment slots. b.   The only route for communication between 111 and the GP were letters sent electronically. c.   The letters were not streamed for urgency by the GP surgery – meaning that the GP could not discriminate those letters that provided a specific  instruction for action and those that did not require action. In this case there  was a seven-day delay between the letter arriving at the surgery and it being considered by a GP.

In my opinion action should be taken to prevent future deaths and I believe you [AND/OR your organisation] have the power to take such action.

You are under a duty to respond to this report within 56 days of the date of this report, namely by 10 th July 2023 . I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed.