In Profession news

Follow this topic

Bookmark

Record learning outcomes

A coroner examining the case of a 22-month old child who died from Streptococcus A-related sepsis has raised concerns that a practice-based pharmacist - who was not employed directly by the surgery - had not been advised on the appropriate use of medical records pathways.

Michael Pemberton, assistant coroner for west Manchester, found that a lack of clarity around information sharing pathways and triage tools at Ashton Medical Practice led to a "missed opportunity" to review the decision to stop antibiotics for Hailey Anne Thompson.

Mr Pemberton stressed that this was not a "causative" factor in Hailey's death - but said future deaths may be prevented if lessons are learned from the circumstances of the case. 

Hailey was brought to her GP on December 7, 2022 and prescribed antibiotics to treat bacterial tonsillitis, but these were stopped after three days after she developed a rash that was "thought to be an allergic reaction".

Hailey "remained unwell" and saw her GP again on December 16 before attending A&E the next day. On both occasions a viral upper respiratory infection was diagnosed and therefore antibiotics were not indicated. 

On the morning of December 19 she was found unresponsive and brought to the Royal Albert Infirmary in Wigan, where attempts to resuscitate her were unsuccessful.

"The cause of  death was sepsis, arising from Streptococcus A infection in the lungs causing pneumonia," Mr Pemberton wrote.

The assistant coroner noted that when Hailey's mother had contacted the surgery an administrative member of staff, who made an appointment for a pharmacist working at the surgery to call her.

He wrote: "The pharmacist to whom this was assigned was not competent to deal with a paediatric medication enquiry and sent a message back advising of this, albeit not on the medical records system where an auditable trail would exist. 

"On the evidence, the pharmacist was not provided with feedback directly on the need to use the medical  records system or involved in the lessons learned process as they were not directly employed by the practice."

Mr Pemberton added that there were concerns that practice managers "may not have a clear pathway" for referrals or a triage tool "to recognise that a reported allergic reaction to a medication may require urgent consideration by a doctor to assess any risk of anaphylactic shock".

He said he had seen no evidence to show how a patient phoning the practice might be referred to an urgent triage doctor or whether call centre staff were given "a list of clinician competencies and whom to refer tasks to".
 
While he emphasised that these circumstances at the primary care level did not contribute to Hailey's death, he added: "These issues are important as I had no reassurance that an administrative member of staff who spoke with a patient contacting the practice, had a clear pathway or  guidance on whom the required task should be referred to."

His report was issued to Ashton Medical Centre and GP practice group SSP Health, as well as to Wigan Integrated Care Board. These organisations are obliged to respond to the assistant coroner by May 30 this year.