Patricia Ann Douglas · Prevention of Future Deaths report

On 03/12/2020 I opened an inquest into the death of Patricia Ann Douglas who died aged 76 on 28/9/20. It is hoped a full hearing will take place early in the new year.

Mrs Douglas contacted the NHS 111 service at 11.49 on Sunday 27/9/20 complaining of severe breathlessness, and reporting that she had experienced similar symptoms 2 weeks previously and had been very anaemic requiring a blood transfusion. The call handler’s questioning took her down a route that ended in a suspicion that the symptoms may be due to Covid-19 and Mrs Douglas was informed that a doctor from the Covid Clinical Assessment service (CCAS) would call her back. A General Practitioner working for CCAS did try to contact Mrs Douglas 3 times between 13.30 & 13.38 but was unable to do so, believing the patient’s phone to be engaged when in fact her telephone number had not been fully recorded on the referral passed from NHS 111. No further action was taken “Call closed as per protocol”. Mrs Douglas and her husband waited all day for the call back. The following day her condition was worsening, her GP contacted who arranged an emergency ambulance. Mrs Douglas was taken to A&E in Carlisle, arriving at 10.03, severely unwell, she collapsed during initial assessment and could not be resuscitated. Post mortem severe coronary atherosclerosis and a complete blockage of one artery was found, she tested negative for Covid-19.

[BRIEF SUMMARY OF MATTERS OF CONCERN]
(1) The initial assessment by the NHS 111 call handler led her down a pathway leading to a referral to the Covid service and does not seem to have given weight to the history of anaemia and transfusion. Could the pathway be improved to give better guidance to call handlers?
(2) The call was closed by CCAS without further action due to an incorrect telephone number being recorded. The call was from an elderly lady who on the face of it seemed significantly unwell. Would referrals in similar circumstances to local providers [GP or out of hours services] who may be better placed to follow up be worth considering?
(3) This lady rang for help feeling very unwell, I am told she wanted a doctor to visit, unfortunately nothing happened and it seems very likely that an opportunity to investigate and treat her was missed. I note that two GPs would have been working for the OOH provider at Penrith Hospital –just a mile from Patricia’s home, that Sunday afternoon, one based in the hospital and the other doing home visits.