GP lifts lid on ambulance trial in which Cromer patient died

An inquest this month heard how father-of-three Adam Frere-Smith, of Cromer, was one of three patients whose death last November was linked to an ambulance trial which has since been discontinued.

Two weeks on, Dr Peter Harvey, of Aylsham, admitted making an 'unwitting major misjudgement' in Mr Frere-Smith's care but added he was asked to make an assessment on a patient who would normally be considered too seriously injured to be assessed by a GP.

Speaking for the first time since the inquest, he also said the out-of-hours GP service is 'near-disastrously under-funded and under-resourced' compared to patient demand – a problem which the public 'needs to understand'.

Mr Frere-Smith, 48, died from a brain haemorrhage following a fall, but the attending East of England Ambulance (EEAST) paramedic thought his head injury was a minor wound.

As part of the pilot the paramedic, Jeff Billings, rang Dr Harvey to ask for treatment advice, and the pair decided that he did not need hospital treatment – but Mr Frere-Smith died 24 hours later.

Today Dr Harvey, a GP for 25 years, said the episode had hung over him for more than six months and that it had left him demoralised.

'This is the first time an incident remotely like this has come my way,' he said.

He added: 'It makes you question your own worth.'

Dr Harvey has written to this newspaper (see below) to explain the circumstances behind Mr Frere-Smith's death, and also to highlight the wider problems facing the out-of-hours GP service.

One of the reasons the EEAST ran the pilot was to reduce the number of patients taken to busy hospitals' A&E departments when treatment was more appropriate elsewhere, which sometimes occurred after patients failed to get help from out-of-hours primary care services or NHS 111.

Dr Harvey said: 'Patient demand for out-of-hours services has changed significantly in the last few years.

'Rates of pay for out-of-hours GPs is up to 40pc less than in-hours GPs, and the indemnity insurance costs are very high.

'So it's not attractive for GPs to work out-of-hours. I do it because it suits my lifestyle.'

Trust has 'paused' pilot after further deaths occurred

Senior ambulance chief Tom Davis confirmed at the inquest that two other patients had died in similar circumstances to Mr Frere-Smith during the pilot.

Details of those other patients have not been released, but this newspaper understands they occurred in the Essex and Hertfordshire/Bedfordshire localities.

The pilot, which ran from May 2015 to May 2016, was set up to give paramedics the chance to call GPs based at ambulance headquarters to discuss treatment options for patients while at the scene. It was hoped this would ensure more patients were given the correct treatment and not taken to busy hospitals unnecessarily.

But at the inquest Dr Davis, deputy medical director at the EEAST, admitted the organisation 'did not have the oversight to ensure the service was understood by everyone and used appropriately by everyone'.

As well as the deaths, the trial was also linked to one patient who needed intensive care.

The trust has paused the trial and the scheme.

Coroner Johanna Thompson said any such future scheme should be 'heavily monitored'.

Dr Harvey's letter in full

Dear Sir

You may recognise my name as the GP named and involved in the tragic case of Mr Frere-Smith.

There is no doubt that this patient should have been conveyed immediately to hospital where he may have had a chance of surviving this incident, and as such the outcome was a tragedy; no one would deny that.

I'm writing principally in an attempt to explain the circumstances of what went wrong, and why, as I believe it encompasses a greater issue which is of public interest. I do not wish this letter to be abbreviated by you and published as a letter; no – it is a suggestion that I contribute to a small article about the matter, with your co-operation.

Background to myself – I'm a full-time GP and have been working here in Norfolk, where I am from, as a GP since 1991 and also have continued to be one of the very few GPs still working regularly out of hours in some capacity since and to date. This the first time an incident remotely like this has come my way.

Prior to the GP trial I was working regularly for the out of hours provider, the very same ambulance trust, and was a clinical lead for the service for the three years or so leading up to the cessation of the out-of-hours contract at the end of August last year, but had done some sessions also for the new 'GP Triage' service pilot from around April last year. When the out-of-hours contract was recommissioned with IC24 from September there was sufficient demand for GPs to work with the Triage service that I did solely this form of out-of-hours work, right through to the end of the pilot period which was the end of May 2016.

I was not at all involved in commissioning or designing the new service and was asked by the trust to join them for it. You may recall from the early winter last year the enormous pressures faced by the IC24 OOH provider, the region's acute hospitals and the ambulance trust in terms of unacceptable patient waits for call backs, ambulance response times, A/E attendances, across the whole of the GP and urgent care OOH. Moreover the local GP OOH provider was having enormous difficulties recruiting GPs to cover the shifts – all this was publicised by your paper during this time.

The need for this GP triage service was identified as the ambulance trust and A/E were overwhelmed – and a main reason was that crews attending 999 calls to patients (who in turn had resorted to 999 as neither 111 or the GP OOH provider had even called them back) who were not acutely ill but were seeking a range of non-urgent interventions ranging from self-care advice, request to forward information to their GPs, or a consultation with an OOH GP at a local base or a home visit – and sometimes a recognisable acute medical condition could be referred directly to the respective hospital department.

Crews knew that these patients didn't need to go to A/E and hitherto would have phoned the then OOH triage service but by November this was a non-starter as they would have waited literally hours for a call back from 111 – hence the need for this additional in-house GP triage service. At no time was it suggested that we GPs would be involved in decisions about whether to convey patients to A/E or not, especially with a background of trauma. GPs have no hands-on experience of trauma cases and themselves would automatically direct such cases to 999.

Thus – calls coming our way at the GP triage service were those which were already deemed by crews not suitable for A/E conveyance and we were being asked to make suggestions for follow up or on-referral so that the crew could depart and deal with another case. In the case of an alcoholic patient it would have been to do with ensuring they were able to access alcohol services, that their problem was known to their GPs and for mental health presentations whether they were in need of urgent mental health assessment, all of which we, as GPs, were familiar with and able to advise on.

The GP triage service became extremely well used and appreciated by crews over the year, and at times there would be 5 GPs working simultaneously, and trying to call back crews within a few minutes, and on a typical weekend day I would deal with 60 or 70 calls. The service provided the right care at the right time to thousands of the region's patients and doubtlessly had a beneficial knock on effect for patients genuinely needing an emergency ambulance conveyance to A/E, such as Mr Frere-Smith.

However, minor head injuries without ill-effects or complications are extremely common and crews will be able to distinguish them from those needing admission; but occasionally other health issues arise which could be subject to addressing or referring to an OOH GP. Typically it would be a frail elderly patient in a care home who is also discovered to have contributory condition such as a urine infection or heart irregularity.

As a telephone triager you have to form a mental picture of the circumstances at the scene and rely wholly on the testimony of the attending crew, and tragically this is where Mr Frere-Smith's case unravelled. The picture I formed was of a patient whom the crew felt did not have a significant head injury and did not need to be conveyed, but were concerned that he may be in need of support for his on-going alcohol dependency and mental health problems, and this would be consistent with the type of calls we GPs had been getting.

Whilst not making any excuses I would also add that we were being expected to handle and deal with calls as soon as crews contacted us, and there would always be a queue of them wanting a call back, and the whole point of the service was a quick response from a GP about matters which a GP was familiar with. But assessing a head injury in a complex patient on the end of a telephone would absolutely not be a skill that any regular GP has and therefore it would have not occurred to me that that was what the ambulance trust was expecting of me. And as such I made an unwitting major misjudgement and I hope the family at least understands that, though I don't expect any forgiveness.

The wider public interest issue ? It is simply that the whole out-of-hours service is near-disastrously under-funded and under-resourced in terms of matching the demand for it. And the public needs to understand these problems as it is the solution to them. Professionals (still) working in this environment try their best to balance the need of the individual patient trying to access it and the overall effect on all patients given that the service cannot cope with all the demand, be it for 111 advice, GP OOH, dental services, 999 ambulance and A/E.

Dr P Harvey