Amy Hogan
PFD Report
Partially Responded
Ref: 2020-0147
Alcohol, drug and medication related deaths
Community health care and emergency services related deaths
1 of 2 responded · Over 2 years old
Response Status
Responses
1 of 2
56-Day Deadline
2 Dec 2020
Over 2 years old — no identified published response
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Coroner's Concerns
1) The inquest heard evidence from Miss Hogan's regular GP that, despite being requested, the General Practice records from her previous practice never arrived. It is a matter of concern that delayed, incomplete or non-existent transfer of patient data from one practice to another on moving places an unfair burden on patients to accurately recall and relay their own medical histories. It is a matter of particular concern that such issues create particular problems for vulnerable patients, who simply may not be in a position to do so;
2) Notwithstanding numerous previous initiatives as to information-sharing and digitisation of patient data, it is a matter of concern that the out of hours GP reviewing Miss Hogan had no electronic access to her regular GP records. Access to such records would have revealed, amongst other things, Miss Hogan was prescribed the oral contraceptive pill, which is likely to have led the doctor to ask additional questions about her symptoms. Again, it is a matter of particular concern that an inability to access regular GP records in the out of hours setting raises additional risks for vulnerable patients.
2) Notwithstanding numerous previous initiatives as to information-sharing and digitisation of patient data, it is a matter of concern that the out of hours GP reviewing Miss Hogan had no electronic access to her regular GP records. Access to such records would have revealed, amongst other things, Miss Hogan was prescribed the oral contraceptive pill, which is likely to have led the doctor to ask additional questions about her symptoms. Again, it is a matter of particular concern that an inability to access regular GP records in the out of hours setting raises additional risks for vulnerable patients.
Responses
Response received
View full response
Dear Mr Morris,
Re: Regulation 28 Report to Prevent Future Deaths – Miss Amy Hogan 21st January 2020
Thank you for your Regulation 28 Report dated 31st July 2020 concerning the death of Miss Amy Hogan on 21st January 2020. Firstly, I would like to express my deep condolences to Miss Hogan’s family.
The regulation 28 report concludes Miss Hogan’s death was a result of:
1) a) Hypoxic brain injury b) Pulmonary embolism c) Deep vein thrombosis
2) Oral contraceptive pill, obesity
Following the inquest, you raised concerns in your Regulation 28 Report to NHS England relating to the transferring of GP records following registration at a new practice, and access to GP records in an out of hours setting. This response has been made with input from NHSX, the organisation responsible for NHS technology, digital and data - including data-sharing and transparency.
Over recent months significant progress has been made around the access to GP records out of hours. As a response to the pandemic, we have enabled the use of GP-Connect across the whole primary care estate. This eases facilitation for authorised professionals in multiple care settings to directly access in a safe and secure manner GP records which are held at GP out of hours services, CCAS, Extended Access Hubs and NHS 111. We have also enabled wider access by authorised professionals to an enriched Summary Care Record with Additional Information (SCR-AI), which allow a health and care professional to see a patient’s medical history and helps to support older patients and those with complex comorbidities. Over 54 million patient records (90%) of the population in England, now include enriched summary care records. We are working with GP system suppliers and National Medical Director NHS England & NHS Improvement Skipton House 80 London Road London SE1 6LH
29th October 2020
continue to make progress. We are looking at ways to ensure that these changes can be retained for the future given the impact it has had for faster and better care. There is an ongoing programme of work to review and establish and reduce the root cause of electronic GP2GP (GP2GP is the formal term for the programme) record transfer failures. In March 2020 there was an increase applied by GP system suppliers to GP2GP transfer ‘file size’ from 50MB to 100MB, this will subsequently help to reduce the rate of failures further. Due to COVID-19 competing priorities, statistics are not yet available to demonstrate the effect this change has had. However, we anticipate analysis and collection of these metrics will resume as part of the recovery work. We continue to make progress on the digitisation of GP records, including the programme to digitise historic information held in the Lloyd George paper medical records. There are 4 main reasons for digitisation of Lloyd George records:
- safer care for patients,
- release of space within practices to provide additional consultation areas,
- access to the full patient record at the point of care,
- GP contract commitment to digitise all Lloyd George records by March
2022. Lloyd George Paper Records Digitisation Project: Wave 1 Pilot sites:
• Sunderland - Digitised 17 of 38 practices with 132k patient paper records digitisation complete. On completion Sunderland will have digitised 284k patients paper records.
• Lancashire ICP (Morecambe Bay CCG) – Digitisation underway, on completion 350k patients paper records digitised across the CCG
• Birmingham & Solihull CCG – Digitisation underway, on completion 1.3m patients paper records digitised. In total – on completion Wave 1 pilots will have digitised 1.9m patient paper records. Wave 2 Pilots (Procurement Phase – work is underway and due to be completed by March 2022. digitisation of Lloyd George records is March 2022 Participation across all 7 regions o North West – 1.9m o North East & Yorkshire – 804k o Midlands – 1.3m
o East of England – 982k o London – 1.4m o South East – 1.6m o South West – 1.1m In total – on completion Wave 2 have plans approved to digitise 9m patients paper records to be digitised. We sincerely hope that this provides reassurance that progress is being made around the digitisation and transfer of medical records, in order to prevent such tragic events reoccurring in the future. Thank you for bringing these important issues to my attention and please do not hesitate to contact me should you need any further information.
Re: Regulation 28 Report to Prevent Future Deaths – Miss Amy Hogan 21st January 2020
Thank you for your Regulation 28 Report dated 31st July 2020 concerning the death of Miss Amy Hogan on 21st January 2020. Firstly, I would like to express my deep condolences to Miss Hogan’s family.
The regulation 28 report concludes Miss Hogan’s death was a result of:
1) a) Hypoxic brain injury b) Pulmonary embolism c) Deep vein thrombosis
2) Oral contraceptive pill, obesity
Following the inquest, you raised concerns in your Regulation 28 Report to NHS England relating to the transferring of GP records following registration at a new practice, and access to GP records in an out of hours setting. This response has been made with input from NHSX, the organisation responsible for NHS technology, digital and data - including data-sharing and transparency.
Over recent months significant progress has been made around the access to GP records out of hours. As a response to the pandemic, we have enabled the use of GP-Connect across the whole primary care estate. This eases facilitation for authorised professionals in multiple care settings to directly access in a safe and secure manner GP records which are held at GP out of hours services, CCAS, Extended Access Hubs and NHS 111. We have also enabled wider access by authorised professionals to an enriched Summary Care Record with Additional Information (SCR-AI), which allow a health and care professional to see a patient’s medical history and helps to support older patients and those with complex comorbidities. Over 54 million patient records (90%) of the population in England, now include enriched summary care records. We are working with GP system suppliers and National Medical Director NHS England & NHS Improvement Skipton House 80 London Road London SE1 6LH
29th October 2020
continue to make progress. We are looking at ways to ensure that these changes can be retained for the future given the impact it has had for faster and better care. There is an ongoing programme of work to review and establish and reduce the root cause of electronic GP2GP (GP2GP is the formal term for the programme) record transfer failures. In March 2020 there was an increase applied by GP system suppliers to GP2GP transfer ‘file size’ from 50MB to 100MB, this will subsequently help to reduce the rate of failures further. Due to COVID-19 competing priorities, statistics are not yet available to demonstrate the effect this change has had. However, we anticipate analysis and collection of these metrics will resume as part of the recovery work. We continue to make progress on the digitisation of GP records, including the programme to digitise historic information held in the Lloyd George paper medical records. There are 4 main reasons for digitisation of Lloyd George records:
- safer care for patients,
- release of space within practices to provide additional consultation areas,
- access to the full patient record at the point of care,
- GP contract commitment to digitise all Lloyd George records by March
2022. Lloyd George Paper Records Digitisation Project: Wave 1 Pilot sites:
• Sunderland - Digitised 17 of 38 practices with 132k patient paper records digitisation complete. On completion Sunderland will have digitised 284k patients paper records.
• Lancashire ICP (Morecambe Bay CCG) – Digitisation underway, on completion 350k patients paper records digitised across the CCG
• Birmingham & Solihull CCG – Digitisation underway, on completion 1.3m patients paper records digitised. In total – on completion Wave 1 pilots will have digitised 1.9m patient paper records. Wave 2 Pilots (Procurement Phase – work is underway and due to be completed by March 2022. digitisation of Lloyd George records is March 2022 Participation across all 7 regions o North West – 1.9m o North East & Yorkshire – 804k o Midlands – 1.3m
o East of England – 982k o London – 1.4m o South East – 1.6m o South West – 1.1m In total – on completion Wave 2 have plans approved to digitise 9m patients paper records to be digitised. We sincerely hope that this provides reassurance that progress is being made around the digitisation and transfer of medical records, in order to prevent such tragic events reoccurring in the future. Thank you for bringing these important issues to my attention and please do not hesitate to contact me should you need any further information.
Action Should Be Taken
7
Report Sections
Circumstances of the Death
From around September 2019, Miss Hogan began to report sporadic and non-specific symptoms of feeling unwell. Having initially attended the Pennine Medical Centre in Mossley as a visiting patient, Miss Hogan registered with that oractice. Miss Hoaan received treatment from doctors at the practice for depression and anxiety, and continued to be prescribed the oral contraceptive pill following a risk assessment by the practice pharmacist. On 2011h January 2020, Miss Hogan attended the out of hours doctor at Oldham Primary Care hub, reporting a 3 day history of feeling light headed, weak and drained. Whilst Miss Hogan had told others she had experienced breathlessness and leg pain,'this information was not conveyed to the out of hours doctor. Whilst Miss Hogan disclosed to the doctor details of the anti-depressant medication she had been prescribed, he was not informed she was taking the oral contraceptive pill. I I I The following day, Miss Hogan became acutely unwell and collapsed at I her home. She was taken to hospital by ambulance where she died.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.