Audrey Lily Kelly · Prevention of Future Deaths report

On 21st November 2013 I commenced an investigation into the death of Audrey Lily Kelly dob 16th September 1923. The investigation concluded on the 3rd April 2014 and the conclusion was that she died from natural causes. The medical cause of death was 1a Acute myocardial insufficiency 1b Coronary Artery atheroma II. Systemic Hypertension.

On the 17th November 2013 Mrs Kelly complained of abdominal pain and the out of hours doctor was called to attend. The doctor was unable to access her GP medical notes and was unaware that she was in fact known to be allergic to Trimethoprim. He prescribed the antibiotic to her and she took three of the tablets as prescribed. She was then found deceased at her home two days later. The initial cause for concern was that she had consumed these tablets to which she was allergic, though in fact it turned out that the cause of her death was due to natural causes.

During the course of the evidence it was made very clear to me by the attending doctor who prescribed the medication and also by the nurse who took the call at the Out of Hours service that they could not /are not allowed to obtain and see the electronic notes held by the patient's own GP. This fact was backed up by a senior administrator of the Out of Hours service who reiterated that neither they nor the hospital Emergency Departments, have direct access to GP Notes.
It seems to me that this is a serious lapse in the procedures and will inevitably lead to further lives being lost when, if the notes were available, those lives might be saved.
In the case of the Out of Hours service it seems particularly absurd that these notes are not available when in fact the Out of Hours doctor is deputising for that very GP who
not allowing access to the notes.
It would appear therefore that there is an immediate need for directions to be issued to ALL OUT OF HOURS PROVIDERS and the appropriate Clinical Commissioning Groups to the effect that there must be free and unfettered access to ALL the GP notes in these circumstances.