David Nash
PFD Report
All Responded
Ref: 2023-0033Deceased
All 1 response received
· Deadline: 28 Mar 2023
Coroner's Concerns (AI summary)
The primary care complaints process failed to obtain a clinical rationale from the GP practice, leading to flawed initial reviews. It's unclear how learning is shared with practices and networks.
View full coroner's concerns
I heard evidence that David's father made a complaint to NHSE about the primary care service, namely the GP Practice, that David had had contact with. This resulted in a clinical review of that complaint by Dr D'Souza which was initially highly critical of the 4 occasions of care which David had at his GP Practice (listed above)
It appears that this complaint was handled without a clinical rationale from the GP Practice being provided which resulted in reviewing his opinion once that information was provided in the anticipation of inquest proceedings. I heard evidence from the GP Practice that they were not made aware of the concerns raised by until the inquest process had disclosed these concerns.
I am unclear how the primary care complaints team ensure that the details from their clinical reviews are fully informed taking account of information provided from complainants and those involved in the clinical management of a patient and how that information is then shared back to the practice to ensure appropriate learning can be undertaken. I am also not clear of the process of cascading this information to the primary care network in general where that is appropriate to raise awareness of an issue or condition for example.
It appears that this complaint was handled without a clinical rationale from the GP Practice being provided which resulted in reviewing his opinion once that information was provided in the anticipation of inquest proceedings. I heard evidence from the GP Practice that they were not made aware of the concerns raised by until the inquest process had disclosed these concerns.
I am unclear how the primary care complaints team ensure that the details from their clinical reviews are fully informed taking account of information provided from complainants and those involved in the clinical management of a patient and how that information is then shared back to the practice to ensure appropriate learning can be undertaken. I am also not clear of the process of cascading this information to the primary care network in general where that is appropriate to raise awareness of an issue or condition for example.
Responses
Action Planned
NHS England will remind regional complaints teams to share final responses with providers, include a reference to the Report in the next National Learning Report, and remind teams to liaise with coroners when inquests run parallel to complaints. (AI summary)
NHS England will remind regional complaints teams to share final responses with providers, include a reference to the Report in the next National Learning Report, and remind teams to liaise with coroners when inquests run parallel to complaints. (AI summary)
View full response
Dear Ms Combes, Re: Regulation 28 Report to Prevent Future Deaths – David John Nash who died on 4 November 2020. Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated Tuesday 31 January 2023, concerning the death of David John Nash on 4 November
2020. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to David’s family and loved ones. NHS England are keen to assure the family and the coroner that the concerns raised about David’s care have been listened to and reflected upon. I am grateful for the further time granted to respond to your Report, and I apologise for any anguish this delay may have caused to David’s family or friends. I realise that responses to Coroner Reports can form part of the important process of family and friends coming to terms with what has happened to their loved ones and appreciate this will have been an incredibly difficult time for them. Your Report raised the following concerns over how complaints made about the primary care service provided to David were handled:
1. That the complaint was handled without a clinical rationale from the GP Practice being provided which resulted in the clinical reviewer revising their opinion once that information was provided in the anticipation of inquest proceedings. A review of our records indicates that when the review was undertaken it included the clinical rationale from the GP Practice. As part of their clinical review, the clinical reviewer requested further information from the practice which included specific records and transcripts. This was provided and the clinical review was completed. In response to a request from the complainant seeking further clarification on comments attributed to the clinical reviewer in the complaint response, a further clinical review was provided. Whilst this provided further clarification in relation to comments made, it did not represent a change in clinical view.
2. That the GP Practice was not made aware of the concerns raised by the clinical reviewer until the inquest process had disclosed these concerns. You raised that it was unclear how the NHS England Primary Care Complaints Team ensured that their clinical reviews are fully informed and National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG
25 April 2023
how information is shared back to a service/Practice to ensure appropriate learning can be taken. Our review has shown it appears that copies of the complaint responses were not shared with the GP practice. NHS England apologises for this and for any distress caused to the family. NHS England updated its complaints policy in October 2021, to state that all responses must be shared with the provider and this change should have been acknowledged and acted upon. We will ensure all regions are reminded of the complaints policy and the need to be compliant with the policy.
3. That it was not clear on the general process for cascading information to a Primary Care Network where it is appropriate to raise awareness of an issue or condition. It is not NHS England policy to routinely share information with Primary Care Networks, however, agreed ways of working and processes are in place to ensure sharing and learning from complaints. Regionally, this is carried out through the quality processes in locality teams and Integrated Care Boards (ICBs) to ensure that any learning is shared, and that GP Practices are appropriately supported. Nationally, cascading of information and the dissemination of learning is implemented through something called the National Learning Report. NHS England will include a reference to your Report to Prevent Future Deaths in the next National Learning Report and ensure the learning around the handling of complaints is included. Regarding the above, NHS England will be taking the following actions to address the concerns raised in your Report:
1. NHS England will ensure that all regional complaints teams are reminded of the requirement to share a copy of its final response with the provider(s) concerned, in line with NHS England policy.
2. NHSE can confirm that we will include a reference to your Report and the concerns raised in the next National Learning Report and ensure the learning around the handling of complaints is included.
3. NHS England will remind all regional complaints teams that it is good practice to liaise with a coroner when an inquest is running parallel to a complaint. I would also like to provide further assurances on national NHSE work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around preventable deaths are shared across the NHS at both a national and regional level and helps us pay close attention to any emerging trends that may require further review and action.
Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information.
2020. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to David’s family and loved ones. NHS England are keen to assure the family and the coroner that the concerns raised about David’s care have been listened to and reflected upon. I am grateful for the further time granted to respond to your Report, and I apologise for any anguish this delay may have caused to David’s family or friends. I realise that responses to Coroner Reports can form part of the important process of family and friends coming to terms with what has happened to their loved ones and appreciate this will have been an incredibly difficult time for them. Your Report raised the following concerns over how complaints made about the primary care service provided to David were handled:
1. That the complaint was handled without a clinical rationale from the GP Practice being provided which resulted in the clinical reviewer revising their opinion once that information was provided in the anticipation of inquest proceedings. A review of our records indicates that when the review was undertaken it included the clinical rationale from the GP Practice. As part of their clinical review, the clinical reviewer requested further information from the practice which included specific records and transcripts. This was provided and the clinical review was completed. In response to a request from the complainant seeking further clarification on comments attributed to the clinical reviewer in the complaint response, a further clinical review was provided. Whilst this provided further clarification in relation to comments made, it did not represent a change in clinical view.
2. That the GP Practice was not made aware of the concerns raised by the clinical reviewer until the inquest process had disclosed these concerns. You raised that it was unclear how the NHS England Primary Care Complaints Team ensured that their clinical reviews are fully informed and National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG
25 April 2023
how information is shared back to a service/Practice to ensure appropriate learning can be taken. Our review has shown it appears that copies of the complaint responses were not shared with the GP practice. NHS England apologises for this and for any distress caused to the family. NHS England updated its complaints policy in October 2021, to state that all responses must be shared with the provider and this change should have been acknowledged and acted upon. We will ensure all regions are reminded of the complaints policy and the need to be compliant with the policy.
3. That it was not clear on the general process for cascading information to a Primary Care Network where it is appropriate to raise awareness of an issue or condition. It is not NHS England policy to routinely share information with Primary Care Networks, however, agreed ways of working and processes are in place to ensure sharing and learning from complaints. Regionally, this is carried out through the quality processes in locality teams and Integrated Care Boards (ICBs) to ensure that any learning is shared, and that GP Practices are appropriately supported. Nationally, cascading of information and the dissemination of learning is implemented through something called the National Learning Report. NHS England will include a reference to your Report to Prevent Future Deaths in the next National Learning Report and ensure the learning around the handling of complaints is included. Regarding the above, NHS England will be taking the following actions to address the concerns raised in your Report:
1. NHS England will ensure that all regional complaints teams are reminded of the requirement to share a copy of its final response with the provider(s) concerned, in line with NHS England policy.
2. NHSE can confirm that we will include a reference to your Report and the concerns raised in the next National Learning Report and ensure the learning around the handling of complaints is included.
3. NHS England will remind all regional complaints teams that it is good practice to liaise with a coroner when an inquest is running parallel to a complaint. I would also like to provide further assurances on national NHSE work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around preventable deaths are shared across the NHS at both a national and regional level and helps us pay close attention to any emerging trends that may require further review and action.
Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information.
Sent To
- NHS England
Response Status
Linked responses
1 of 1
56-Day Deadline
28 Mar 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
Report Sections
Investigation and Inquest
On 13 November 2020 an investigation commenced into the death of David John Nash born on 26 August 1994. The investigation concluded at the end of the inquest on 20 January 20223. The conclusion of the inquest was:-
David died on 4 November 2020 at Leeds General Infirmary as a result of a brain-stem infarction, arising from a cerebella abscess caused by mastoiditis. On 2 November 2020 there was a missed opportunity to direct David to seek face-to-face care during his GP appointment that morning. Had he been directed to seek face-to-face or urgent care by the GP Practice it is more likely than not that he would have undergone neurosurgery approximately 10 hours earlier than he actually did; which at that time it is more likely than not would have been successful.
The medical cause of death was:
1a: Brain-stem infarction 1b: Cerebellar abscess 1c: Mastoiditis
David died on 4 November 2020 at Leeds General Infirmary as a result of a brain-stem infarction, arising from a cerebella abscess caused by mastoiditis. On 2 November 2020 there was a missed opportunity to direct David to seek face-to-face care during his GP appointment that morning. Had he been directed to seek face-to-face or urgent care by the GP Practice it is more likely than not that he would have undergone neurosurgery approximately 10 hours earlier than he actually did; which at that time it is more likely than not would have been successful.
The medical cause of death was:
1a: Brain-stem infarction 1b: Cerebellar abscess 1c: Mastoiditis
Circumstances of the Death
1. David first spoke to his GP on the phone about some swollen lumps on his neck on 14 October 2020. He was advised that he should have blood tests and these were booked for 2 November 2020.
2. On 23 October 2020 he further sought advice from the GP because he had pain in his ear and was complaining of an ear infection. At this telephone appointment there was an assessment for mastoiditis and otitis externa was diagnosed. Antibiotic ear drops were prescribed.
3. He was then spoken to on the phone again on 28 October 2020 because he felt that he had blood in his urine. He was advised to deliver a urine sample to the Practice which he did and when tested contained blood and white cells resulting in further antibiotics being prescribed. The view of the GP expert was that this was unlikely to be a UTI however there would be no basis on which a GP would link these symptoms to mastoiditis and therefore the treatment was not unreasonable on this occasion.
4. From the evidence of , ENT consultant it is more likely than not that at some point in the days after this appointment, David began to develop the abscess that would ultimately prove fatal.
5. On 2 November 2020 David had a telephone consultation with an ANP at his practice. He had continued fever, pain behind his eye and sinus pain. He had had a negative covid-19 swab in the week prior to this appointment but nevertheless his blood tests were cancelled and he was advised not to visit the surgery but to take a further Covid-19 swab and await the results. This clearly unsettled David who was concerned to get his blood tests completed and the ANP gave reassurance that as soon as he had a negative covid-19 swab she would book him in for his blood tests and see him urgently in practice.
6. As the 2 November 2020 progressed David became increasingly unwell. This resulted in David's partner contacting NHS 111. She explained his symptoms and was advised that a clinician would call back within 6 hours. Unfortunately David then vomited and so his partner called NHS 111 again and was given the same advice. When a clinician did call David's partner was advised not to wake him if he was sleeping and to keep up to date with the codeine pain relief. About an hour later David began to be disorientated and his partner made a final call to NHS 111 resulting in an ambulance being called.
7. David was placed on the dental pathway for NHS 111 which meant that he missed the opportunity to be asked questions which may have identified mastoiditis. However this pathway at the time was not unreasonable for him on the basis of his symptoms.
8. David was taken to St James' Hospital initially. He was triaged quickly and a working diagnosis of either meningitis or encephalitis was made. Both of these conditions would be treated at St James'. He required a CT scan which was undertaken just over 2 hours after it was booked. This was within the context of an ED suffering significant pressures.
9. As soon as the CT scan was undertaken it was apparent how unwell David was and urgent steps were taken to transfer him to the LGI for neurosurgery.
10. Unfortunately whilst David was in the resuscitation part of ED he deteriorated very significantly and suffered a fall resulting in head lacerations. This fall did not contribute to his death but nevertheless represented an acute deterioration in his condition with his GCS going from 10 to 3 and requiring immediate ventilation.
11. David survived to the LGI and underwent surgery to insert an external ventricular drain. This appeared to be a successful procedure at first and David responded however he continued to deteriorate over the course of the 3 and 4th of November 2020 and clinicians determined that his condition was unsurvivable.
12. David died at the LGI on 4 November 2020.
2. On 23 October 2020 he further sought advice from the GP because he had pain in his ear and was complaining of an ear infection. At this telephone appointment there was an assessment for mastoiditis and otitis externa was diagnosed. Antibiotic ear drops were prescribed.
3. He was then spoken to on the phone again on 28 October 2020 because he felt that he had blood in his urine. He was advised to deliver a urine sample to the Practice which he did and when tested contained blood and white cells resulting in further antibiotics being prescribed. The view of the GP expert was that this was unlikely to be a UTI however there would be no basis on which a GP would link these symptoms to mastoiditis and therefore the treatment was not unreasonable on this occasion.
4. From the evidence of , ENT consultant it is more likely than not that at some point in the days after this appointment, David began to develop the abscess that would ultimately prove fatal.
5. On 2 November 2020 David had a telephone consultation with an ANP at his practice. He had continued fever, pain behind his eye and sinus pain. He had had a negative covid-19 swab in the week prior to this appointment but nevertheless his blood tests were cancelled and he was advised not to visit the surgery but to take a further Covid-19 swab and await the results. This clearly unsettled David who was concerned to get his blood tests completed and the ANP gave reassurance that as soon as he had a negative covid-19 swab she would book him in for his blood tests and see him urgently in practice.
6. As the 2 November 2020 progressed David became increasingly unwell. This resulted in David's partner contacting NHS 111. She explained his symptoms and was advised that a clinician would call back within 6 hours. Unfortunately David then vomited and so his partner called NHS 111 again and was given the same advice. When a clinician did call David's partner was advised not to wake him if he was sleeping and to keep up to date with the codeine pain relief. About an hour later David began to be disorientated and his partner made a final call to NHS 111 resulting in an ambulance being called.
7. David was placed on the dental pathway for NHS 111 which meant that he missed the opportunity to be asked questions which may have identified mastoiditis. However this pathway at the time was not unreasonable for him on the basis of his symptoms.
8. David was taken to St James' Hospital initially. He was triaged quickly and a working diagnosis of either meningitis or encephalitis was made. Both of these conditions would be treated at St James'. He required a CT scan which was undertaken just over 2 hours after it was booked. This was within the context of an ED suffering significant pressures.
9. As soon as the CT scan was undertaken it was apparent how unwell David was and urgent steps were taken to transfer him to the LGI for neurosurgery.
10. Unfortunately whilst David was in the resuscitation part of ED he deteriorated very significantly and suffered a fall resulting in head lacerations. This fall did not contribute to his death but nevertheless represented an acute deterioration in his condition with his GCS going from 10 to 3 and requiring immediate ventilation.
11. David survived to the LGI and underwent surgery to insert an external ventricular drain. This appeared to be a successful procedure at first and David responded however he continued to deteriorate over the course of the 3 and 4th of November 2020 and clinicians determined that his condition was unsurvivable.
12. David died at the LGI on 4 November 2020.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.