Evelyn Swift
PFD Report
Historic (No Identified Response)
Ref: 2019-0354
Coroner's Concerns (AI summary)
The medical group lacked safe procedures for triaging patients, allocating home visits, providing urgent clinical advice, documenting calls, and ensuring sufficient clinical capacity; they also lacked processes to review significant events and learn from them.
View full coroner's concerns
1. The Beechdale Medical Group did not have safe procedures in place to triage patients when they presented as unwell.
2. The Beechdale group did not have safe procedures in place for the allocation of homevisits.
3. The Beechdale group did not have an allocated clinician available each day that was accessible by the Practice team, and available to provide urgent clinical advice
4. The Beechdale Medical Group did not have safe processes in place to ensure that all calls from patients were documented, nor safe processes to ensure that contemporaneous notes made during a home visit were recorded on the patient record.
5. The Beechdale Group did not have sufficient clinical capacity to ensure safe clinical cover arrangements at each location where services are provided.
6. The Beechdale group did not have processes in place to review a significant event, such as a sudden death when there was Practice involvement on the day prior to the death, with no understanding of the need to review and learn as a Practice from such events.
2. The Beechdale group did not have safe procedures in place for the allocation of homevisits.
3. The Beechdale group did not have an allocated clinician available each day that was accessible by the Practice team, and available to provide urgent clinical advice
4. The Beechdale Medical Group did not have safe processes in place to ensure that all calls from patients were documented, nor safe processes to ensure that contemporaneous notes made during a home visit were recorded on the patient record.
5. The Beechdale Group did not have sufficient clinical capacity to ensure safe clinical cover arrangements at each location where services are provided.
6. The Beechdale group did not have processes in place to review a significant event, such as a sudden death when there was Practice involvement on the day prior to the death, with no understanding of the need to review and learn as a Practice from such events.
Sent To
- Beechdale Medical Group
Response Status
Linked responses
0 of 1
56-Day Deadline
14 Jan 2020
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 the 8th January 2019, I commenced an investigation into the death of Evelyn Ann Swift. The investigation concluded at the end of the inquest on 15th August 2019. The conclusion of the inquest was a narrative conclusion as follows: Evelyn Ann Swift died at her home address in Nottingham, on 4th January 2019, at the age of seventy five, from pneumonia. She also had Ischaemic heart disease that made a contribution to her death. The assessment of her condition on the previous day was incomplete and underestimated the severity of her symptoms, such that a hospital admission was not arranged. This was a missed opportunity to arrange appropriate medical care. It is not possible to say whether or not she would have survived had she been admitted on 3rd January 2019.
Circumstances of the Death
Mrs Swift (Ann) was known to have Chronic Obstructive Pulmonary Disease, and was on inhaler treatment. She became unwell over the few days prior to her death, and contacted the GP surgery on 3rd January 2019 to request a home visit. The home visit was not arranged until the evening of 3rd January 2019, by which time Ann had rung on five occasions, and was more unwell. The home visit was completed by a nurse from the Practice. She did not have the full information regarding Ann’s past medical history nor treatment, nor the knowledge that Ann had contacted the surgery frequently during the day. The clinical assessment made during the home visit was incomplete and the severity of her condition not recognised. She was not admitted to hospital and was found deceased the following morning at her home address.
Further detail regarding the circumstances of Ann’s death are described in the attached judgment.
Further detail regarding the circumstances of Ann’s death are described in the attached judgment.
Copies Sent To
Care Quality Commission for their information
Inquest Conclusion
Evelyn Ann Swift died at her home address in Nottingham, on 4th January 2019, at the age of seventy five, from pneumonia. She also had Ischaemic heart disease that made a contribution to her death. The assessment of her condition on the previous day was incomplete and underestimated the severity of her symptoms, such that a hospital admission was not arranged. This was a missed opportunity to arrange appropriate medical care. It is not possible to say whether or not she would have survived had she been admitted on 3rd January 2019.
Similar PFD Reports
Reports sharing organisations, categories, or themes
Related Inquiry Recommendations
Public inquiry recommendations addressing similar themes
Address BTP systemic failings from Volume 1
Manchester Arena Inquiry
No open learning culture
Quality and safety oversight
Address Arena failings identified in Volume 1
Manchester Arena Inquiry
No open learning culture
Quality and safety oversight
Address Showsec failings identified in Volume 1
Manchester Arena Inquiry
No open learning culture
Quality and safety oversight
LRF oversight of lessons from exercises and incidents
Manchester Arena Inquiry
No open learning culture
Quality and safety oversight
Board Awareness of SAI Reports
Hyponatraemia Inquiry
No open learning culture
Quality and safety oversight
Policy on Learning from SAI Deaths
Hyponatraemia Inquiry
No open learning culture
Quality and safety oversight
SAI Deaths in Annual Reports
Hyponatraemia Inquiry
No open learning culture
Quality and safety oversight
Care Quality Commission independence strategy and culture
Mid Staffs Inquiry
No open learning culture
Quality and safety oversight
Urgently use outside consultants to review safety management and communication issues
Hidden Inquiry
No open learning culture
Quality and safety oversight
Urgently introduce independent monitoring and auditing for all safety-related work
Hidden Inquiry
No open learning culture
Quality and safety oversight
Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.