Christine Cumbers
PFD Report
All Responded
Ref: 2023-0196
All 1 response received
· Deadline: 11 Aug 2023
Sent To
Response Status
Responses
1 of 1
56-Day Deadline
11 Aug 2023
All responses received
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
The Practice, despite identifying shortcomings in their practice, took no action to implement the learnings identified in the Significant Event Analysis report and, as at the date of the inquest, no details of plans or timescales for implementation were available.
Responses
Response received
View full response
Dear Ms Mellani This is the Clacton Community Practices’ (“the Practice”) response to your Rule 28 Prevention of Future Deaths report issued on 19 June 2023 in relation to Christine Margaret Cumbers – date of death 22 April 2022. We have read your report made in accordance with paragraph 7 of Schedule 5 to the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroner’s (Investigation). Rules 2013. We have also read the Coroner’s concerns regarding a lack of implementation of learnings, in particular, no detailed plans or timescales, for addressing the shortcomings identified in our Significant Event Analysis (“SEA”) The shortcomings you have identified in the Practice or the Practice’s SEA are:
1. A lack of follow up following the failed home visit on 24 March 2022
2. The consultation on 28 March did not meet the required standards and the management plan was incorrect. The Practice’s answers to the identified shortcomings are as follows:
1. Failed Visits
It is customary for the CCP to contact patients with failed visits within 24 hours. This happened in the case of Mrs Cumbers, as a doctor contacted her on two separate occasions on 25 March 2022. We note that Mrs Cumbers did contact the surgery on 24 March, a few hours after the failed pre-arranged visit. We consider that, whilst it would have been the gold standard for a health care professional (HCP) to be able to speak to Mrs Cumbers directly when she rang to explain why the doctor had failed to gain entry, it was entirely reasonable for Mrs Cumbers to be advised by a non-clinical member of staff at that time, following a clinician’s risk assessment. Such risk assessments are always HCP dependent and include factors such as: · reason for visit · living arrangements i.e. does the patient live alone · past medical history · carer support etc.
Part of Ranworth Medical Group
Ranworth Surgery
Nayland Road Surgery Caradoc Surgery
Frinton Road Medical Centre Green Elms Health Centre Epping Close Surgery
The SEA document intended to highlight the inability to guarantee a clinician will be available at every contact a patient makes with the CCP in such circumstances. Consequently, as a practice we believe it is safe for a person to receive signposting / safety netting from member of staff trained in care navigation (similar to all 111 hubs nationally) under the supervision of a clinician following their risk assessment. As this is what happened in Mrs Cumbers case, the CCP does not believe any further action is necessary.
2. Consultation Standard A serious event analysis (SEA) on Mrs Cumbers identified a consultation which fell below expected standard. Had this not been the case, it could have led to her being admitted 24 hours earlier. This raised a concern, even if this did not contribute to her death. It is customary to address such concerns, which relate to an individual’s sub-standard interaction with the relevant clinician in first instance by way of refresher training and reflection in order to minimise recurrence. As there was no identified systemic failure, the Practice addressed the concern identified in the SEA as described above (with the individual clinician involved) as well as disseminating learning at a practice meeting on 9/8/22 in an anonymous manner, to promote reporting. This said, the Practice also strives to go beyond what is common practice and this is the reason why we decided to audit consultations retrospectively to essentially promote reflection and improve patient care. We can confirm this was completed ahead of schedule on 31/7/23. As detailed in the SEA, it was agreed that every clinician would have at the very least one consultation audited against a known criteria (NHSE audit XL template) once a year and their result sent to them to be discussed with their appraiser. Appraisals are held yearly and are a means to help clinicians reflect on their practice to assure they continue to meet GMC standards. Hence this kind of sporadic monitoring (not mandated anywhere in the country) can never be a valid substitute nor give assurance on overall performance of a given clinician but is rather a quality improving exercise. We hope this fully addresses the Coroner’s concerns, but please do hesitate to contact us if you require any further information.
1. A lack of follow up following the failed home visit on 24 March 2022
2. The consultation on 28 March did not meet the required standards and the management plan was incorrect. The Practice’s answers to the identified shortcomings are as follows:
1. Failed Visits
It is customary for the CCP to contact patients with failed visits within 24 hours. This happened in the case of Mrs Cumbers, as a doctor contacted her on two separate occasions on 25 March 2022. We note that Mrs Cumbers did contact the surgery on 24 March, a few hours after the failed pre-arranged visit. We consider that, whilst it would have been the gold standard for a health care professional (HCP) to be able to speak to Mrs Cumbers directly when she rang to explain why the doctor had failed to gain entry, it was entirely reasonable for Mrs Cumbers to be advised by a non-clinical member of staff at that time, following a clinician’s risk assessment. Such risk assessments are always HCP dependent and include factors such as: · reason for visit · living arrangements i.e. does the patient live alone · past medical history · carer support etc.
Part of Ranworth Medical Group
Ranworth Surgery
Nayland Road Surgery Caradoc Surgery
Frinton Road Medical Centre Green Elms Health Centre Epping Close Surgery
The SEA document intended to highlight the inability to guarantee a clinician will be available at every contact a patient makes with the CCP in such circumstances. Consequently, as a practice we believe it is safe for a person to receive signposting / safety netting from member of staff trained in care navigation (similar to all 111 hubs nationally) under the supervision of a clinician following their risk assessment. As this is what happened in Mrs Cumbers case, the CCP does not believe any further action is necessary.
2. Consultation Standard A serious event analysis (SEA) on Mrs Cumbers identified a consultation which fell below expected standard. Had this not been the case, it could have led to her being admitted 24 hours earlier. This raised a concern, even if this did not contribute to her death. It is customary to address such concerns, which relate to an individual’s sub-standard interaction with the relevant clinician in first instance by way of refresher training and reflection in order to minimise recurrence. As there was no identified systemic failure, the Practice addressed the concern identified in the SEA as described above (with the individual clinician involved) as well as disseminating learning at a practice meeting on 9/8/22 in an anonymous manner, to promote reporting. This said, the Practice also strives to go beyond what is common practice and this is the reason why we decided to audit consultations retrospectively to essentially promote reflection and improve patient care. We can confirm this was completed ahead of schedule on 31/7/23. As detailed in the SEA, it was agreed that every clinician would have at the very least one consultation audited against a known criteria (NHSE audit XL template) once a year and their result sent to them to be discussed with their appraiser. Appraisals are held yearly and are a means to help clinicians reflect on their practice to assure they continue to meet GMC standards. Hence this kind of sporadic monitoring (not mandated anywhere in the country) can never be a valid substitute nor give assurance on overall performance of a given clinician but is rather a quality improving exercise. We hope this fully addresses the Coroner’s concerns, but please do hesitate to contact us if you require any further information.
Report Sections
Investigation and Inquest
On 10 May 2022 I commenced an investigation into the death of Christine Margaret Cumbers. The investigation concluded at the end of the inquest on 19 May 2023. The conclusion of the inquest was a narrative conclusion: Christine Margaret Cumbers suffered with Hyperthyroidism and was admitted to hospital with a skin rash eruption secondary to Carbimazole use, a rare but recognised complication of this necessary Hyperthyroidism first line medical treatment. She developed sepsis during her hospital admission which was belatedly diagnosed and treated due to lack of continuity care caused by multiple ward moves. The belated diagnosis and treatment of sepsis more than minimally contributed to her death on 22 April 2022 at Colchester General Hospital, Essex.
Circumstances of the Death
Christine Margaret CUMBERS was born on 3 September 1948 and at the time of her death on 22 April 2022 she lived in Clacton-on-Sea, Essex.
Mrs Cumbers was known to have Hyperthyroidism, Hypertension, Osteoarthritis, Hypercholesterolaemia and a stable Angina. On 29 March 2022, Mrs CUMBERS was admitted to Colchester Hospital, having presented with skin eruption following use of Carbimazole, prescribed for an overactive Thyroid, by her GP at above named Practice. Mrs Cumbers suffered an allergic reaction to the prescribed Carbimazole, she stopped Carbimazole and reported it to the GP practice on 21 March. She was seen by a GP on 22 March in person, on 24 March there was a failed home visit with no follow up call directly to Mrs Cumbers, on 25 March there was a consultation via telephone, on 28 March she spoke to reception and later a nurse over the telephone and on 29 March she was seen at home. The GP Practice carried out an internal review of the incident, including the consultations conducted by the various GPs and other clinical staff and produced a “Significant Event Analysis” report. This report was admitted as evidence as part of the coronial investigation and identified that a clinician should have followed up on the failed encounter and the consultation on 28 March did not meet the required standards and the management of the care was found to be wrong, leading to a delay in administration of antibiotics and hospital admission. The evidence showed that this event did not cause or contributed to the death on the balance of probabilities. However, the Practice confirmed in evidence that no actions have been taken to embed the learnings identified in the Significant Event Analysis report, to ensure the appropriate standards are upheld by the Practice’s clinical staff when carrying out consultations and providing treatment.
Mrs Cumbers was known to have Hyperthyroidism, Hypertension, Osteoarthritis, Hypercholesterolaemia and a stable Angina. On 29 March 2022, Mrs CUMBERS was admitted to Colchester Hospital, having presented with skin eruption following use of Carbimazole, prescribed for an overactive Thyroid, by her GP at above named Practice. Mrs Cumbers suffered an allergic reaction to the prescribed Carbimazole, she stopped Carbimazole and reported it to the GP practice on 21 March. She was seen by a GP on 22 March in person, on 24 March there was a failed home visit with no follow up call directly to Mrs Cumbers, on 25 March there was a consultation via telephone, on 28 March she spoke to reception and later a nurse over the telephone and on 29 March she was seen at home. The GP Practice carried out an internal review of the incident, including the consultations conducted by the various GPs and other clinical staff and produced a “Significant Event Analysis” report. This report was admitted as evidence as part of the coronial investigation and identified that a clinician should have followed up on the failed encounter and the consultation on 28 March did not meet the required standards and the management of the care was found to be wrong, leading to a delay in administration of antibiotics and hospital admission. The evidence showed that this event did not cause or contributed to the death on the balance of probabilities. However, the Practice confirmed in evidence that no actions have been taken to embed the learnings identified in the Significant Event Analysis report, to ensure the appropriate standards are upheld by the Practice’s clinical staff when carrying out consultations and providing treatment.
Similar PFD Reports
Reports sharing organisations, categories, or themes with this PFD
Related Inquiry Recommendations
Public inquiry recommendations addressing similar themes
Uniform policy for obtaining technical advice
Scottish Hospitals Inquiry
Major project lessons learned
Streamlining NHS construction quality procedures
Scottish Hospitals Inquiry
Major project lessons learned
Independent validation of hospital construction
Scottish Hospitals Inquiry
Major project lessons learned
Clarify whether HCRS and OCS assessment processes differ
Post Office Horizon Inquiry
Major project lessons learned
Reconsider Phase 1 recommendations in light of Phase 2
Grenfell Tower Inquiry
Major project lessons learned
Add legal requirements warning to statutory guidance
Grenfell Tower Inquiry
Major project lessons learned
Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.