James Taylor
PFD Report
Partially Responded
Ref: 2020-0300
Coroner's Concerns (AI summary)
Inadequate transfer summaries between GP practices for complex patients lead to critical clinical information being missed and compromise continuity of care.
View full coroner's concerns
As a result of his complex health needs, Mr Taylor changed address on a number of occasions. This required a number of changes of general practitioner surgeries. In 4 years, Mr Taylor had changed surgeries 4 times. The Inquest heard evidence from his final general practitioner who confirmed that there was a large volume of records relating to Mr Taylor. The GP confirmed that no summary of care is provided to GP practices when transfer of patients take place. He confirmed the dangers of this, in that important clinical matters can be missed where a patient has a large volume of records.
The general practitioner indicated that handover summaries should be provided to GPs when complex patients are transferred from surgery to surgery. Such transfer summaries could include a summary of past medical history and highlight acute, ongoing clinical conditions, together with any safeguards around prescribing of medication. Such summaries could ensure safety in the continuity of care
The general practitioner indicated that handover summaries should be provided to GPs when complex patients are transferred from surgery to surgery. Such transfer summaries could include a summary of past medical history and highlight acute, ongoing clinical conditions, together with any safeguards around prescribing of medication. Such summaries could ensure safety in the continuity of care
Responses
Noted
The Royal College of General Practitioners explained the current system for transferring GP records, supporting electronic transfer (GP2GP) for its advantages. They clarified that the responsibility for the transfer system lies with Primary Care Support England, not the RCGP itself. (AI summary)
The Royal College of General Practitioners explained the current system for transferring GP records, supporting electronic transfer (GP2GP) for its advantages. They clarified that the responsibility for the transfer system lies with Primary Care Support England, not the RCGP itself. (AI summary)
View full response
Dear Ms Persaud, Re: Inquest touching upon the death of James David Alexander Taylor Regulation 28 (Preventing Future Deaths) report Thank you for your letter of 23 Dec 2020 regarding the death of Mr Taylor. Please pass on my condolences to his family and friends am replying as Joint Honorary Secretary of the Royal College of General Practitioners The Royal College of General Practitioners (RCGP) is the largest membership organisation in the United Kingdom solely for GPs_ It aims to encourage and maintain the highest standards of general medical practice and to act as the 'voice' of GPs on issues concerned with education; training; research; and clinical standards Founded in 1952,the RCGP has just over 54,000 members who are committed to improving patient care, developing their own skills and promoting general practice as a discipline From your letter; it would appear that Mr Taylor had a number of complex problems, particularly following a road traffic collision It is also clear that Mr Taylor changed GP surgeries on four occasions prior tO unfortunately his own life understand that the question you have posed is regarding the structure of the GP records that are transferred from one surgery to another and specifically with regard to a summary problem list and medication In responding to this question;, it is worth noting that general practice in the UK is the most computerised element of the health service and has been so for many years_ It is now very rare that handwritten notes are made and GPs rely upon specialist computer systems to record and transfer records, as patients move from one surgery to another The standards and approaches are governed by NHS England and NHS Digital but in summary include not just the content but also the structure of record keeping There are a number of GP IT suppliers but the largest is EMIS, which supports the majority of GP surgeries in England Within the computer programmes, they automatically populate a current and/or significant problem list and secondly an inactive problem list _ Examples Royal College of General Practitioners 30 Euston Square, London; NW1 2FB Tel: 020 3188 7400 info@rcgp orguk rcgp org uk Patron: HRH The Duke of Edinburgh Registered Charity Number 223106 taking they
of the former might be a serious health problem such as heart attack or significant mental health difficulty for the latter, 3 more routine problem such asa chest infection which would initially be in the current problem list and then move onto the inactive list after a period of time They also automatically document immediate and repeat prescriptions In terms of notes moving from one practice to another; almost always this is a "pull system" whereby it is registration of the patient at their new chosen surgery that starts a process of the previous medical notes being transferred. Whilst in a small number of occasions, a patient may indicate that they are moving to another surgery and give an opportunity for the "leaving" practice to have a clinical handover to the "receiving" practice, this is relatively rare; although when there are complex problems it can be helpful Increasingly, although not universally; upon registration, medical records are transferred electronically using a system called GPZGP electronic transfer. See details here which is run by Primary Care Support England. This has the important set of advantages that the whole record is transferred across and usually seamlessly- This would include any active problem lists; medications and other details It is also much quicker: However, paper transfer is also used this still requires that the "leaving" surgery print out the full medical record and the "receiving" surgery to then g0 through the record, scan it and act upon any obvious issues There are clearly potential timing and resource risks with this latter process have attached the necessary guidance from Primary Care Support Services for your information The responsibility for the system of transferring records lies with Primary Care Support England rather than RCGP, but our position is to support electronic transfer for the reasons articulated above trust that this reply is helpful and if you have any questions please do not hesitate t0 contact
of the former might be a serious health problem such as heart attack or significant mental health difficulty for the latter, 3 more routine problem such asa chest infection which would initially be in the current problem list and then move onto the inactive list after a period of time They also automatically document immediate and repeat prescriptions In terms of notes moving from one practice to another; almost always this is a "pull system" whereby it is registration of the patient at their new chosen surgery that starts a process of the previous medical notes being transferred. Whilst in a small number of occasions, a patient may indicate that they are moving to another surgery and give an opportunity for the "leaving" practice to have a clinical handover to the "receiving" practice, this is relatively rare; although when there are complex problems it can be helpful Increasingly, although not universally; upon registration, medical records are transferred electronically using a system called GPZGP electronic transfer. See details here which is run by Primary Care Support England. This has the important set of advantages that the whole record is transferred across and usually seamlessly- This would include any active problem lists; medications and other details It is also much quicker: However, paper transfer is also used this still requires that the "leaving" surgery print out the full medical record and the "receiving" surgery to then g0 through the record, scan it and act upon any obvious issues There are clearly potential timing and resource risks with this latter process have attached the necessary guidance from Primary Care Support Services for your information The responsibility for the system of transferring records lies with Primary Care Support England rather than RCGP, but our position is to support electronic transfer for the reasons articulated above trust that this reply is helpful and if you have any questions please do not hesitate t0 contact
Action Taken
Barking, Dagenham, Havering and Redbridge CCG and NELFT have implemented changes to the Psychological Therapies service, including updating standard operating procedures, increasing service capacity, and reviewing panel protocols to manage risks associated with waiting lists. They are also planning a formal service review and considering further investment. (AI summary)
Barking, Dagenham, Havering and Redbridge CCG and NELFT have implemented changes to the Psychological Therapies service, including updating standard operating procedures, increasing service capacity, and reviewing panel protocols to manage risks associated with waiting lists. They are also planning a formal service review and considering further investment. (AI summary)
View full response
Dear Miss Persaud
Re: Inquest touching upon the death of Mr James Alexander David Taylor,
Regulation 28 Report
I write in response to the Prevention of Future Deaths Report issued to Redbridge Clinical Commissioning Group on the 21 December 2020, following the Coroner’s inquest into the death of Mr James Alexander David Taylor.
The CCG commissioning lead and NELFT heads of service have met to discuss the Coroner’s concerns set out in the Regulation 28 report and agreed actions to prevent future deaths.
Some changes to the standard operation procedure for the Psychological Therapies service were implemented in 2018, which address some of the concerns of the Coroner and further actions have been agreed to reduce the risk of a similar incident occurring again.
Please find attached a report for the Coroner on the actions that have been taken.
The CCG strives to learn from incidents and to constantly improve the service provision it provides. Please do not hesitate to contact me if you require any clarification.
Thank you for your helpful insights into this case.
Re: Inquest touching upon the death of Mr James Alexander David Taylor,
Regulation 28 Report
I write in response to the Prevention of Future Deaths Report issued to Redbridge Clinical Commissioning Group on the 21 December 2020, following the Coroner’s inquest into the death of Mr James Alexander David Taylor.
The CCG commissioning lead and NELFT heads of service have met to discuss the Coroner’s concerns set out in the Regulation 28 report and agreed actions to prevent future deaths.
Some changes to the standard operation procedure for the Psychological Therapies service were implemented in 2018, which address some of the concerns of the Coroner and further actions have been agreed to reduce the risk of a similar incident occurring again.
Please find attached a report for the Coroner on the actions that have been taken.
The CCG strives to learn from incidents and to constantly improve the service provision it provides. Please do not hesitate to contact me if you require any clarification.
Thank you for your helpful insights into this case.
Sent To
- Continuing Care
- Continuing Care, Redbridge Clinical Commissioning Group and Royal College of General Practitioners
- Redbridge Clinical Commissioning Group and Royal College of General Practitioners
Response Status
Linked responses
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Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On 12th November 2020 I commenced an investigation into the death of James Alexander David Taylor, 35 years old. The investigation concluded at the end of the inquest on 11th December 2020. The conclusion of the inquest was a narrative conclusion:
Mr Taylor died as a result of suicide. He took his own life following life changing injuries sustained during a road traffic collision. The injuries sustained in the collision caused a functional neurological disorder manifesting in refractory pain and sensory disturbances. These, in turn, led to psychological distress and suicidal ideation. Mr Taylor sought help for his pain and psychological distress. Long-term psychological therapy was required. The required help was not provided to him. In August 2019, Mr Taylor attended a long awaited multi-disciplinary programme for functional neurological disorder. He had attended preparatory sessions for the in-patient programme, to determine his suitability. The extent of his pain was not explored at the preparatory sessions and his engagement in the programme was terminated after 4 days, due to pain limiting his engagement. It is clear from communication left by Mr Taylor that the feeling of rejection from this programme contributed to his decision to take his own life.
Mr Taylor died as a result of suicide. He took his own life following life changing injuries sustained during a road traffic collision. The injuries sustained in the collision caused a functional neurological disorder manifesting in refractory pain and sensory disturbances. These, in turn, led to psychological distress and suicidal ideation. Mr Taylor sought help for his pain and psychological distress. Long-term psychological therapy was required. The required help was not provided to him. In August 2019, Mr Taylor attended a long awaited multi-disciplinary programme for functional neurological disorder. He had attended preparatory sessions for the in-patient programme, to determine his suitability. The extent of his pain was not explored at the preparatory sessions and his engagement in the programme was terminated after 4 days, due to pain limiting his engagement. It is clear from communication left by Mr Taylor that the feeling of rejection from this programme contributed to his decision to take his own life.
Circumstances of the Death
The immediate circumstances of the death can be seen from the narrative conclusion set out above.
In relation to the primary health care provided to Mr Taylor, concerns were raised by his family and friends in relation to the number of different general practitioner surgeries involved in his care and the lack of continuity of care.
Evidence was heard from his final GP, who confirmed that Mr Taylor had a very large volume of medical records due to his complex physical and mental health needs. The practice received an electronic transfer of records. There was no transfer letter or clear summary of his ongoing clinical needs.
In relation to the primary health care provided to Mr Taylor, concerns were raised by his family and friends in relation to the number of different general practitioner surgeries involved in his care and the lack of continuity of care.
Evidence was heard from his final GP, who confirmed that Mr Taylor had a very large volume of medical records due to his complex physical and mental health needs. The practice received an electronic transfer of records. There was no transfer letter or clear summary of his ongoing clinical needs.
Copies Sent To
who in my opinion should receive it
You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response. 23/12/2020 SIGNED BY CORONER
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.