Cynthia Fretwell · Prevention of Future Deaths report

On 16th October 2013, I commenced an investigation into the death of Cynthia Fretwell, aged 84. The investigation concluded at the end of the inquest on 12th November 2013. The conclusion of the inquest was:
On the 12th day of February 2013 Cynthia Fretwell died as a result of peritonitis as a result of an infected gall bladder which had not responded to treatment by antibiotics.

Mrs Fretwell had a history of abdominal pain and on 8th February 2013, she was admitted to the emergency department of the Queens Medical Centre in Nottingham. She had been diagnosed by her GP as having obstructive jaundice following a home visit. Upon admission Mrs Fretwell, was treated with antibiotics as the working diagnosis was of an inflamed gall bladder and localised peritonitis. Mrs Fretwell’s condition improved and she was discharged on 9th February 2013 to continue a course of antibiotics in the community. On 11th February 2013, Mrs Fretwell’s GP visited her at home as she was feeling unwell. It was noted that she was suffering from a temperature, tenderness in her gallbladder and jaundice. Mrs Fretwell was not admitted to hospital. On 12.02.13 Mrs Fretwell’s family contacted her GP again as Mrs Fretwell was still not well. A telephone consultation took place but Mrs Fretwell was not seen in person by the GP. Mrs Fretwell remained at home and was not admitted into hospital. She died at 11.25pm that evening.

(1) Telephone referrals and the lack of an effective system for conveying and responding to information between the caller and the doctor. Specifically, I had concerns about the following aspects:
(a) The inability of reception staff to interrupt a GP during surgery for the purposes of alerting and informing the doctor of a change in the patient’s condition following a telephone referral.
(b) Timely consultation and timely responses to telephone referrals from patients and their families.
(c) The threshold for determining whether a telephone consultation is adequate or whether a home consultation should be undertaken.

(2) A full assessment of the patient’s mental capacity in a situation where they are refusing medical treatment or admission to hospital.

(3) Full and proper documentation of the discussions between the doctor and the patient/patient’s family in those circumstances.

In the course of oral evidence taken at the inquest on the 16.10.2013, I was informed of changes that had been instituted by the Hama Medical Centre since the death of Mrs Fretwell which would address these concerns. I adjourned the inquest on the 16th October 2013 to provide an opportunity to the Hama Medical Centre to comment the detail of changes to writing. I asked that a report be filed by 4pm on 30th October 2013 and the matter was re-listed on 12th November 2013.

I received a report from the Hama Medical Centre dated 21st October 2013. I was satisfied from the contents of that letter and its attachments that matters 1(a) & (b) of the concerns above had been addressed. However, there was no reference to (c) and the remaining issues of concern which had been identified. In the circumstances therefore, I consider the response inadequate and feel my duty to report has been invoked.