The coroner for the Isle of Wight area, Caroline Sumeray, has found at inquest that issues in relation to the ability of different doctors to modify hospital records and delete test results may have been a contributing factor in the death of a patient suffering from peritonitis and a perforated duodenal ulcer. She has since made a recommendation for action to prevent future deaths arising out of the same scenario.
Ms Sumeray’s recently published report sets out the following background.
Joseph Dunne was 58 years old at the time of his death and worked as a chef. He was a relatively heavy drinker and smoked approximately 20 cigarettes a day. He had been diagnosed with diabetes and had hypertension which was controlled with medication. He had recently lost a significant amount of weight. On Tuesday 14 July, Mr Dunne visited his GP complaining of pain down one side of his body and that he felt generally unwell. As the GP feared that the pain might be cardiac related, an ambulance was requested, which took Mr Dunne to the A&E department of St Mary’s Hospital in Newport, Isle of Wight, arriving at approximately 6pm. Various routine tests and investigations were carried out during the four hours that he was at the hospital, including tests for D-dimer (a test for blood clots)and a chest X-ray, which were ordered by the FY2 doctor who examined Mr Dunne. The D-dimer results were authorised in the laboratory at 8.27pm and phoned through to another emergency department doctor at approximately 8.30pm. This result, as well as an entry relating to his chest X-ray, were entered into the clinical record under the FY2 doctor’s login at 8.30pm, but the person who entered the information is unidentifiable. Both entries were then simultaneously deleted from Mr Dunne’s notes. The FY2 doctor re-entered the information about the chest X-ray at 9.38pm, but the D-dimer result was not re-transcribed. It was believed that the FY2 may have deleted the earlier results as they had been entered under another user’s login.
Regrettably, no consideration or weight was later given to the D-dimer result. Mr Dunne was subsequently discharged at approximately 10pm that evening with a diagnosis of suspected pleurisy. The following day, he re-attended his GP’s surgery and complained that he still felt unwell. His GP arranged for him to be visited at home by the community matron on Thursday 16 July. On that morning, Mr Dunne got up but still felt unwell and returned to bed. His partner went out at 10am. At approximately 2pm, the community matron visited his house and found him collapsed but conscious on the living room floor. He was very cold with a temperature of 34.2C. His partner was summonsed and she returned home. At around 2.15pm, Mr Dunne indicated that he wished to use the toilet and was supported by his partner, but while on the toilet he suddenly became unresponsive and collapsed to the floor. An ambulance was immediately called and CPR was carried out by the community matron. When the paramedics attended, they took over the CPR, but there were no signs of life and he was pronounced dead at 3.20pm.
The coroner expressed concerns that Mr Dunne’s D-dimer result was deleted and therefore not considered by the A&E team, and at the fact that doctors could alter other doctors’ entries in patient records. She made a report on the prevention of future deaths in a similar scenario, which required St Mary’s Hospital to look into its systems, and concluded: “I am concerned that there are breaches in information governance (IG) protocols. It is clear that there are IG issues which allow one clinician to make entries or delete information from a patient’s medical records when they are not correctly logged into the database, or are doing so under a colleague’s log-in (which remains live after they’ve walked away from the computer terminal). Matters are compounded inasmuch as these edits are then found to be invisible to those clinicians who are actually treating the patient, and are only ascertainable when an IT audit trail is undertaken. It should not be possible for Doctor A to be able to access records made by Doctor B and to alter those medical records.”
Philippa Luscombe, a partner in the clinical negligence team at Penningtons Manches, comments: “It is a fact of life that in hospitals, particularly in busy A&E departments, multiple staff can be involved in the management of a patient. It is important therefore that the records reflect all steps taken and information gathered. In this case the coroner was concerned that a test result which could be key to decisions about managing a patient could be entered by one doctor and deleted by another. The consequences of this could be very serious.
“Part of a coroner’s role in looking at an unexpected death is to consider whether the events leading to the death could happen again. A coroner has the power to make a report requiring steps to be taken to prevent similar deaths, and this is one of the constructive actions that can come out of the inquest process. It is easy to see how future errors in management could be caused by mistakes of this type. We hope that this is not part of a more widespread problem, but again the publication of the coroner’s findings and required actions should draw attention to this issue.”