Coroner calls for improvement in handling of medical notes
- Credit: Family submission
A coroner is to write to health bosses in Norfolk calling for an improvement in the way medical notes are handed over and read by doctors before treating patients in emergency departments.
Yvonne Blake, area coroner for Norfolk, said she was concerned by evidence given by doctors over whether they read medical notes and how junior staff are supported.
Her comments were made after the inquest of Brian Havard, who died from a tear in an artery carrying blood from the heart while being taken to the Norfolk and Norwich University Hospital (NNUH) by ambulance on January 9 last year.
It was the second time the 52-year-old from High Kelling had been taken to the NNUH in 24 hours having previously been admitted to A&E the night before complaining of chest pain, only to be discharged a few hours later with what was believed to be pain caused by persistent coughing.
An inquest into Mr Havard's death held in Norwich yesterday heard evidence from Gwendoline Day, Mr Havard's partner who he was living with at the time, who described the events of January 8 and 9.
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The hearing heard how Mr Havard was taken to hospital late at night on January 8 after complaining of chest pain and vomiting, but once he arrived at the NNUH had to wait around four hours in the back of an ambulance before he was admitted into the emergency department (ED).
Douglas Andrews, a junior doctor, told the court how he assessed Mr Havard once he was in ED, requesting a series of medical tests, including a chest x-ray and an ECG.
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The hearing also heard how Dr Andrews queried the results of the ECG with a senior colleague, who did not go and see Mr Havard.
Questioned by the coroner on whether he read Mr Havard's notes and asked for a full patient history, Dr Andrews said he was not aware Mr Havard had vomited blood while in the ambulance and had assumed medication Mr Havard was on had been prescribed by his GP.
After giving a narrative conclusion, Ms Blake said; 'I was not impressed by the medical evidence, there is no evidence that Dr Andrews read Mr Havard's notes before he saw him and his note taking was brief to the extreme.'
Ms Blake accepted that there was little evidence to lead doctors to the fact that Mr Havard might have suffered a bleed to an artery when he was first admitted to hospital.
'I remain concerned that a senior doctor did not set eyes on the patient,' she said.
Following the inquest, Aileen Havard, Mr Havard's widow, said; 'I'm pleased that the inquest has vindicated the concerns I had about the communication and the reporting between the doctors.
'For us Brian will always be a major part of my life that's missing now. He was such a larger than life character. It's difficult to imagine a world without him in it,' she said.
In a statement, Erika Denton NNUH medical director said: 'Our sincere condolences and apologies go out to the family and friends of Mr Havard following their loss.
'A full and thorough review of the care he received at NNUH took place and Mr Havard's family have been fully informed throughout this process and the lessons that have been learnt following his death.
'An action plan has been put in place to ensure that we learn from what happened – this includes further training for emergency department staff and we have developed and expanded our Rapid Assessment and Treatment areas for patients arriving at ED by emergency ambulance.
'Formal teaching sessions about aortic dissection have taken place in ED and we are grateful to Mrs Havard who recently attended the department to talk with staff.'