UK Inquiry Tracker

Paula Elsley

PFD Report All Responded Ref: 2024-0361

Date of Report 6 February 2024

Coroner Robert Simpson

Coroner Area Berkshire

Response Deadline est. 29 August 2024

Hospital Death (Clinical Procedures and medical management) related deaths

Judiciary.uk Report PDF

All 1 response received · Deadline: 29 Aug 2024

Coroner's Concerns (AI summary)

GPs failed to routinely record accessible smoking status and consistently apply NICE guidelines for chest x-rays, and the lack of a formal policy for referral thresholds risks missed cancer diagnoses.

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1. Smoking status During the inquest I heard evidence that a patient's smoking status (current or former) was not routinely recorded by the GP practice in a manner that was immediately accessible when reviewing the medical records. I heard that it may be necessary to search through consultation notes and other records to discover this information and GPs do not necessarily have time to do so. A patient's current or former smoking status is relevant information for a GP considering whether a chest x-ray ought to be considered in line with NICE guideline entitled 'Suspected cancer: recognition and referral' (NG12). The GPs who gave evidence agreed that it would be helpful if this information was flagged and the GP practice has indicated that it intends to introduce such a system. However this is not yet in place and I am concerned that the risk of this information not being highlighted remains a current risk.
2. Thresholds for referral for a chest xray Based on evidence heard at inquest I am concerned that at the time of Paula's death (March 2022) the same NICE guideline was not being routinely considered by GPs. I was very pleased to hear that the practice subsequently introduced their own internal tool for considering if the threshold for a chest x-ray had been reached and that this has been discussed at GP and partner meetings. However some 22 months have now elapsed since Paula's death and no formal policy has been prepared. I remain concerned that the risk of the guideline not being considered remains whilst the change is procedure is informal, especially when it needs to be disseminated to new or locum GPs and other healthcare professionals such as nurses, paramedics and physician associates.

Responses

Ringmead Medical Group Other

1 Jul 2024

Action Taken
The practice has discussed the importance of documenting smoking status and checking for it during consultations, as well as highlighting NICE guidelines for when to request chest x-rays for patients with respiratory symptoms, including dissemination of this information to locum GPs and allied health professionals. They report an increase in chest X-ray requests as a result. (AI summary)

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Dear Sir I write to you regarding 'Regulation 28 report to prevent future death' that was issued following the inquest after the unfortunate death of Paula Elsley. I apologise profusely for the delay in sending my reply as we (in the practice) were not sure about the nature of reply that was required. Following the inquest we (all the partners) discussed in detail about the concerns expressed during the inquest. We discussed about easy visibility of the patient's smoking status which would be very useful during consultation. We considered the possibility of making the smoking status visible immediately when the patient's notes were opened but due to IT issues concerning more than 42000 patients that was thought not to be feasible but is easily visible when looking at care history. The issues were discussed in detail in partner's meeting and subsequent clinical meeting which is usually attended by all clinicians. We discussed about the need for checking and documenting smoking status and went through details regarding how to find it in the patient's notes easily (care history page). The second issue of concern was having a low threshold for conducting a Chest X ray in patients presenting with an ongoing cough or respiratory symptoms. Again, this was discussed in detail in the clinical meetings, guidelines issued by NICE was stressed upon. It is difficult to have a written guideline in the practice about when to request a chest Xray as one needs to assess the patient clinically, but we have stressed that persistent respiratory symptoms, and multiple courses of antibiotics (more than twice) especially in a smoker should prompt the need to carry out a chest X-ray. The clinical meeting is also attended by the Allied health professionals who are regularly involved with seeing patients with respiratory symptoms. We can definitely say that our Chest X ray requests have definitely: delete as repetition gone up which has also been helped by the Hospital Radiology being available over

weekends. This information has also been circulated to Locum GPs as well. Hopefully the above measures will help us to reduce future preventable deaths in the practice. With regards

GP Partner Ringmead Medical Practice Bracknell RG12 7WW

Sent To

Ringmead Medical Group

Response Status

Linked responses 1 of 1

56-Day Deadline 29 Aug 2024

All responses received

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Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.

Source: Courts and Tribunals Judiciary

Report Sections

Investigation and Inquest

On 11 April 2022 I commenced an investigation into the death of Paula Elizabeth ELSLEY aged 54. The investigation concluded at the end of the inquest on 06 February 2024. The conclusion of the inquest was that: On the 28th March 2022 Paula Elizabeth Elsley died at her home address in Birch Hill, Bracknell. She was suffering from undiagnosed lung cancer with a metastatic tumour in her brain. This secondary tumour itself lead to the formation of an abscess which caused her death.

Circumstances of the Death

On the 9th December 2021 Paula spoke to a GP on the phone reporting an ongoing cough. She had previously reported a shortness of breath in November 2021 which improved with antibiotics. She had also reported left leg pain and her leg giving way in the same month. Paula was not assesed further on this occasion and given worsening advice. On the 5th January 2022 Paula spoke to a GP reporting a new chest pain. She was not assessed further and given worsening advice. On the 17th February 2022 she spoke to another GP reporting back and leg pains. She was offered an assessment at the musculoskeletal clinic but declined. Paula had visited an osteopath on the 8th February and did so again on the 21st February. On the 25th February 2022 she reported to a GP that she had almost collapsed and that her legs had felt like jelly. The GP was concerned by these symptoms and booked her for a face to face assessment on the 1st March 2022. On the 4th March 2022 Paula attended the emergency department with left leg weakness, new left arm weakness and intermittent headaches. She was admitted for further investigations but decided to leave prior to these being completed. An outpatient MRI was arranged. On the 16th March 2022 she returned to the emergency department due to the severity of her headaches which were causing her to black out. She was not admitted on this occasion and was due to attend her MRI on the 27th March 2022. She did not make this scan due to circumstances beyond her control. Paula was found unresponsive at home on the 28th March 2022 and declared deceased. A post-mortem examination revealed a primary lung tumour with abscess formation and a brain abscess. The brain abscess was likely the result of a secondary brain tumour.