The Department of Health (DH) has instructed all primary care trusts (PCTs) to review the use of paper-based systems by out of hours providers following the case of a patient who died after speaking to eight different out of hours doctors over a bank holiday weekend.
The DH has acted after coroner Andrew Reid wrote to the health sceretary following an inquest into the death of Penny Campbell, a journalist, who died after a series of doctors from the Camidoc out of hours service in north London failed to diagnose that she was developing septicaemia following an injection for haemorrhoids.
It became clear at the inquest that Campbell’s care had been based on a series of handwritten clinical notes rather than an electronic record system and Reid ruled that although there had not been a gross lack of medical attention, crucial clinical information had been missing and "was not always readily available to the last doctor in the chain."
Duncan Selbie, commissioning director for the DH, wrote to strategic health authority chief executives last month to highlight new directions which require every PCT to review the systems currently in operation by out-of-hours providers, particularly where manual processes for recording clinical notes on call sheets are still in operation.
The letter adds: “The directions require PCTs to ensure that arrangements are fit for purpose and assure the continuity of care.”
PCTs are expected to carry out the reviews by the end of this month. Reviews must cover arrangements for how clinical notes are recorded and made accessible to other out of hours health professionals and GPs.
If arrangements are not considered satisfactory, PCTs are instructed to agree changes to the contract with the out of hours provider so that adequate systems are in place or, if that is not possible, PCTs are instructed to impose the requirements. In cases where the PCT itself is the provider trusts are instructed to ensure that adequate arrangements are introduced.
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