Bronwyn Williams
PFD Report
All Responded
Ref: 2017-0215
All 2 responses received
· Deadline: 8 Nov 2017
Coroner's Concerns (AI summary)
An urgent dental referral was sent by slow postal service, and the subsequent maxillofacial appointment was significantly delayed for nearly seven weeks due to cancellation and rescheduling.
View full coroner's concerns
Some matters have already been dealt with following Ms Williams’ death. However, MATTERS OF CONCERN remain as follows.
1. I heard at inquest that the urgent referral from Kindandental to the Homerton was made not by logging on to a portal, or by email, or by fax, but by post. This seems unduly slow, cumbersome and prone to mishap.
2. Following Ms Williams’ attendance at the dental surgery on 4 May, an appointment with the maxillofacial unit was made for 30 May, then cancelled by the Homerton on 23 May and re-fixed for 19 June. This date is nearly seven weeks post referral.
1. I heard at inquest that the urgent referral from Kindandental to the Homerton was made not by logging on to a portal, or by email, or by fax, but by post. This seems unduly slow, cumbersome and prone to mishap.
2. Following Ms Williams’ attendance at the dental surgery on 4 May, an appointment with the maxillofacial unit was made for 30 May, then cancelled by the Homerton on 23 May and re-fixed for 19 June. This date is nearly seven weeks post referral.
Responses
Action Planned
Homerton University Hospital is implementing electronic referrals via e-RS for GPs by April 2018. They are taking actions to mitigate risks related to dentists not being able to use the system, as they cannot fix the issues locally. (AI summary)
Homerton University Hospital is implementing electronic referrals via e-RS for GPs by April 2018. They are taking actions to mitigate risks related to dentists not being able to use the system, as they cannot fix the issues locally. (AI summary)
View full response
Dear Coroner Hassell,
Re: Inquest touching the death of Bronwyn Williams- Prevention of Future Deaths Report
Thank you for your email sent on 15th September 2017, which contained a Prevention of Future Deaths (PFD) report dated 13th September 2017, in which you raised the following concerns;
1. I heard at inquest that the urgent referral from Kindandental to the Homerton was made not by logging on to a portal, or by email, or by fax, but by post. This seems unduly slow, cumbersome and prone to mishap
2. Following Ms Williams’ attendance at the dental surgery on 4 May, an appointment with the maxillofacial unit was made for 30 May, then cancelled by the Homerton on 23 May and re-fixed for 19 June. This date is nearly seven weeks post referral.
I have attached the action plan developed in response to the PFD notice. We are one of the most advanced Trusts in London in relation to fully implementing electronic referrals via the e- RS system, known as Choose and Book, for GPs by April 2018. Unfortunately, although the system could in theory accept referrals from dentists, in practice they cannot use the system for reasons discussed in the action plan. We cannot fix these issues locally, and are therefore taking actions to mitigate the risk that necessarily remains.
I do hope that this information and our action plan provides you with assurance that we are addressing these issues. Please do not hesitate to contact me if you require any further information or wish to discuss this matter further.
Re: Inquest touching the death of Bronwyn Williams- Prevention of Future Deaths Report
Thank you for your email sent on 15th September 2017, which contained a Prevention of Future Deaths (PFD) report dated 13th September 2017, in which you raised the following concerns;
1. I heard at inquest that the urgent referral from Kindandental to the Homerton was made not by logging on to a portal, or by email, or by fax, but by post. This seems unduly slow, cumbersome and prone to mishap
2. Following Ms Williams’ attendance at the dental surgery on 4 May, an appointment with the maxillofacial unit was made for 30 May, then cancelled by the Homerton on 23 May and re-fixed for 19 June. This date is nearly seven weeks post referral.
I have attached the action plan developed in response to the PFD notice. We are one of the most advanced Trusts in London in relation to fully implementing electronic referrals via the e- RS system, known as Choose and Book, for GPs by April 2018. Unfortunately, although the system could in theory accept referrals from dentists, in practice they cannot use the system for reasons discussed in the action plan. We cannot fix these issues locally, and are therefore taking actions to mitigate the risk that necessarily remains.
I do hope that this information and our action plan provides you with assurance that we are addressing these issues. Please do not hesitate to contact me if you require any further information or wish to discuss this matter further.
Action Planned
Kindandental has applied for an NHS net email address and plans to use it for electronic referrals within two weeks of access and training. They also plan to build functionality into their system to send referrals via other email services with patient consent, and reviewed/updated their referral pathways and associated checklist to ensure thorough referral processes, emphasizing verification of patient details. (AI summary)
Kindandental has applied for an NHS net email address and plans to use it for electronic referrals within two weeks of access and training. They also plan to build functionality into their system to send referrals via other email services with patient consent, and reviewed/updated their referral pathways and associated checklist to ensure thorough referral processes, emphasizing verification of patient details. (AI summary)
View full response
Dear Sirs
In response to the Coroner’s concerns detailed in the report dated 13th Sep 2017 this letter details the action taken by Kindandental to reduce the risk of a similar incident occurring.
We have applied, and have subsequently provided the pre-requisite information required, for the use of an NHS net email address. This is the email system for NHS electronic referrals (to comply with NHS patient confidentiality requirements).
We anticipate having this available to us within two weeks, the timeframe indicated to us by NHS net email providers. We further anticipate starting to send referrals using the NHS net email service as soon as this is in place and within a further period of two weeks having trained all staff internally to be fully using this service and no longer sending patient referrals via post.
The specific reason that we have not been using electronic referrals to this point is due to technical issues with NHS net email in the past. We have investigated usage of NHS net email by dental practices and it is not commonly used by NHS dental practices in our locality. We had been formerly informed that use of NHS electronic referrals must be via NHS net email only, for reasons of patient confidentiality. However, our Significant Event investigations recently following the Coroners letter have revealed that we are, in fact, able to send electronic referrals via other email services where we have a patients’ explicit written consent to do so, although we cannot have a confirmation email returned to us acknowledging receipt. This is of interest as it means if we experience any future technical issues with NHS net email we have an alternative electronic means of NHS referral. We anticipate having functionality built into our existing computer system for this within two weeks.
_________________________________________________ www,k i n d a n d e n t a l .com and Associates 99 Newington Green Road, London N1 4QY 020 7226 3897/6215 info@kindandental.com
We have also reviewed our referral pathways and fully updated the information therein. This has been disseminated to all dentists via email. Our computer system logs and manages referrals. We have reviewed this process and re-iterated to staff the importance of all referrals being fully and correctly logged. Our protocol for all referrals has been reviewed and a check list has been created to be followed and adhered to so that correct and up to date information is gathered for the referral. The check list is a laminated document displayed in each surgery.
We have communicated to all staff (via email and in person) the importance of verifying patient information, full address including post code and GP details, at all points where a referral is made and additionally at general check up appointments.
Sincerely,
Principal Dentist
In response to the Coroner’s concerns detailed in the report dated 13th Sep 2017 this letter details the action taken by Kindandental to reduce the risk of a similar incident occurring.
We have applied, and have subsequently provided the pre-requisite information required, for the use of an NHS net email address. This is the email system for NHS electronic referrals (to comply with NHS patient confidentiality requirements).
We anticipate having this available to us within two weeks, the timeframe indicated to us by NHS net email providers. We further anticipate starting to send referrals using the NHS net email service as soon as this is in place and within a further period of two weeks having trained all staff internally to be fully using this service and no longer sending patient referrals via post.
The specific reason that we have not been using electronic referrals to this point is due to technical issues with NHS net email in the past. We have investigated usage of NHS net email by dental practices and it is not commonly used by NHS dental practices in our locality. We had been formerly informed that use of NHS electronic referrals must be via NHS net email only, for reasons of patient confidentiality. However, our Significant Event investigations recently following the Coroners letter have revealed that we are, in fact, able to send electronic referrals via other email services where we have a patients’ explicit written consent to do so, although we cannot have a confirmation email returned to us acknowledging receipt. This is of interest as it means if we experience any future technical issues with NHS net email we have an alternative electronic means of NHS referral. We anticipate having functionality built into our existing computer system for this within two weeks.
_________________________________________________ www,k i n d a n d e n t a l .com and Associates 99 Newington Green Road, London N1 4QY 020 7226 3897/6215 info@kindandental.com
We have also reviewed our referral pathways and fully updated the information therein. This has been disseminated to all dentists via email. Our computer system logs and manages referrals. We have reviewed this process and re-iterated to staff the importance of all referrals being fully and correctly logged. Our protocol for all referrals has been reviewed and a check list has been created to be followed and adhered to so that correct and up to date information is gathered for the referral. The check list is a laminated document displayed in each surgery.
We have communicated to all staff (via email and in person) the importance of verifying patient information, full address including post code and GP details, at all points where a referral is made and additionally at general check up appointments.
Sincerely,
Principal Dentist
Sent To
- Homerton University Hospital NHS Trust ›Homerton University Hospital
- Kindandental
Response Status
Linked responses
2 of 2
56-Day Deadline
8 Nov 2017
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 25 May 2017 I commenced an investigation into the death of Bronwyn Williams, aged 68 years. The investigation concluded at the end of the inquest on 4 September 2017. I made a determination as follows.
Bronwyn Williams died on 23 May 2017 from a retropharyngeal abscess. This is a naturally occurring, albeit rare condition. She had consulted at an accident and emergency unit on 1 May 2017 and been referred to a dentist. She saw her dentist on 4 May 2017 and was referred to a maxillofacial unit. She was due to be seen within two weeks, but the dental surgery system of referral was postal rather than electronic and then the hospital did not provide an appointment within two weeks, so she was not seen again before her death.
Her medical cause of death was: 1a septicaemia/mediastinitis 1b retropharyngeal abscess 1c gum infection 2 type II diabetes mellitus
Bronwyn Williams died on 23 May 2017 from a retropharyngeal abscess. This is a naturally occurring, albeit rare condition. She had consulted at an accident and emergency unit on 1 May 2017 and been referred to a dentist. She saw her dentist on 4 May 2017 and was referred to a maxillofacial unit. She was due to be seen within two weeks, but the dental surgery system of referral was postal rather than electronic and then the hospital did not provide an appointment within two weeks, so she was not seen again before her death.
Her medical cause of death was: 1a septicaemia/mediastinitis 1b retropharyngeal abscess 1c gum infection 2 type II diabetes mellitus
Circumstances of the Death
Ms Williams saw a dentist at Kindandental on 4 May 2017, having attended the emergency unit of Homerton University Hospital on 1 May and been told to visit her dentist, complaining of pain preventing mouth opening other than to a very limited extent, and a general malaise.
Neither intra oral examination nor imaging was possible at the dental surgery, because of the extent of the trismus. The dentist therefore prescribed a five day course of antibiotics and referred Ms Williams to the maxillofacial unit of the Homerton on an urgent basis. The word urgent in this context means that an appointment should be fixed to take place within two weeks.
On 10 May, Ms Williams rang the dental surgery to say that she had seen on her copy of the referral that her road name had been misspelled and her postcode had been omitted. This was rectified and a further referral sent to the Homerton.
Ms Williams died before ever receiving her appointment.
Neither intra oral examination nor imaging was possible at the dental surgery, because of the extent of the trismus. The dentist therefore prescribed a five day course of antibiotics and referred Ms Williams to the maxillofacial unit of the Homerton on an urgent basis. The word urgent in this context means that an appointment should be fixed to take place within two weeks.
On 10 May, Ms Williams rang the dental surgery to say that she had seen on her copy of the referral that her road name had been misspelled and her postcode had been omitted. This was rectified and a further referral sent to the Homerton.
Ms Williams died before ever receiving her appointment.
Copies Sent To
Care Quality Commission for England
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.