Table 4 Summary of Coroners’ reports to prevent future deaths related to GP service provision in or alongside emergency departments (9 reports identified from 1347 reports, 2013–2018)
Report number | Presenting symptom | Initial diagnosis | Actual diagnosis | Summary of report | Key learning from reports |
|---|---|---|---|---|---|
1. Wrong diagnosis | Calf pain | Muscular injury | Deep vein thrombosis (DVT) | A 47-year-old woman presented to the urgent care centre with calf pain. She had a strong family history of DVT but this was not elicited in the history and she was diagnosed with muscular pain. She later died from a pulmonary embolism. | “The A&E expert gave evidence that patients presenting to an urgent care centre, walk in centre or out of hours are a much higher risk group than those who present to their own GP surgery. As a consequence, there must be clinically agreed protocols that at the front end of any facility that receives undifferentiated patients that manage this higher risk population. Patients that present with certain high risk conditions such as chest pain, shortness of breath or calf pain must be directed to a facility that can exclude serious illness and this is usually the nearest A&E.” |
2. Wrong diagnosis | Calf pain | Muscular injury | Deep vein thrombosis (DVT) | A man presented to a walk in centre with calf pain following a driving holiday in France. There was no calf swelling or tenderness and he was diagnosed with a musculoskeletal injury. He was then seen by his own GP a further 3 times but the walk in centre records were not available. He later died of a pulmonary embolism. | “Records of the August appointment (to the walk-in centre) were not available.” |
3. Wrong diagnosis | Shortness of breath | Not documented | Pulmonary embolism (PE) | A 44-year-old man presented to A&E and was streamed to the GP. He died from a pulmonary embolism two days later. | “Mr (), died of a pulmonary embolism having been diverted from accident and emergency assessment 2 days prior to his death. This meant that further tests, which could have led to an earlier diagnosis for his condition were not done. No 111 referral information was available to ‘Front door’ or the ED (emergency department).” |
4. Wrong diagnosis | Chest pain | Non-cardiac chest pain | Adult Cardiac Death Syndrome | A 30-year-old woman presented to the ambulance service with chest pain, normal examination and ECG. She chose to see her GP who thought the pain was non-cardiac, she died a few hours later at home. | “Mrs Y, aged 30 with a family history of heart disease, was seen by ambulance staff with chest pain, and examination and ECG were reported as normal. The GP had not considered the possibility of Sudden Adult Death Syndrome” |
5. Wrong diagnosis | Chest pain | Gastritis | Loeys-Dietz Syndrome (thoracic aneurysm) | A 42-year-old woman with chest pain was seen by an ambulance, had a normal ECG and chose to see her GP for review. She was seen by the local GP and referred to A&E for further investigation. She was streamed to the GP in A&E who referred her back to A&E where she was assessed, treated for gastritis and discharged with no further investigations. The patient’s presenting history of the same pain as her previous aortic dissection and the initial GP referring letter was lost in transfer. She died a few days later. | “Crucially, the only piece of the patient’s presenting history which wasn’t passed on (to the ED doctor from the local GP) was that the pain that she was feeling was the same pain which she had felt back in 2011 when she suffered her previous aortic dissection. Had he been aware of this piece of information, his evidence was that he would have ordered a CT scan.” |
6. Wrong diagnosis | Head injury | Not documented | Intracranial haemorrhage | A man presented to an urgent care centre following a head injury and again the following day with headache and vomiting. No CT was done. He collapsed and died the next day. | “Patients undergoing haemodialysis or significant uraemia are at risk of haemorrhage and this is not commonly known within the medical profession or referred to in relevant NICE guidelines.” |
7. Wrong diagnosis | Head injury | Not documented | Extradural haematoma | A 10-year-old boy presented to A&E following a head injury and was streamed to the urgent GP clinic and discharged. He was seen at home by a paramedic the following day and not brought to hospital. He collapsed the next day whilst waiting to be seen in the GP surgery. He underwent neurosurgery but died a few days later. | “The consultant from the department told me, during the course of his evidence, that it would be good practice for all suspected head injuries to be referred to the A&E team.” |
8. Delayed diagnosis | Unclear | n/a | Sepsis | A patient presented to the emergency department and was booked into the urgent care centre. He was not triaged for over 45 min by which time his condition had deteriorated. | “Staffing levels in the emergency department were not sufficient to be able to follow national or any local policy on treating suspected sepsis.” |
9. Missed diagnosis | Cough | Chest infection | Pneumonia | A 9-month-old baby presented to a walk-in centre 3 times over 3 months with a cough. She was then seen twice by nurse practitioners at her own surgery with the same complaint who could not recall having access to information about the walk in centre visits and did not refer the patient to the GP. She died the following month from bronchopneumonia. | “There appeared to be no guidelines or triggers for when a practice nurse (practitioner) should refer a patient be seen by a doctor.” |