John William Day · Prevention of Future Deaths report

On 7th April 2014 I commenced an investigation into the death of John William Day, aged 76. The investigation has now concluded and no inquest has been held. The medical cause of death was found to be:

1a Acute Exacerbation of Chronic Obstructive Pulmonary Disease
1b
1c
II Cardiac Failure

1) John Day lived alone in a small flat which appeared to be within an assisted living environment with no care on site. He had respiratory issues and was on oxygen for much of the time. He suffered with COPD and heart failure.

2) During the evening of 5th April, Mr Day called a friend to say that he was having problems breathing. The friend called an ambulance for him as she was at work and unable to attend.

3) The ambulance crew arrived and advised that Mr Day should attend hospital. He refused as he has a Do Not Attempt Cardio Pulmonary Respiration (DNACPR) in place. The ambulance crew called for an on-call doctor from the Beacon to attend. Dr Oommen John attended and questioned Mr Day regarding any allergies, of which Mr Day said he had none, before prescribing him Prednisolone and Co-Amoxiclav.

4) ████████ did not have access to Mr Day’s medical records. Had he been able to access them, he would have seen that Mr Day was, in fact, allergic to Co-Amoxiclav.

5) Mr Day was found dead in his chair whilst still attached to his oxygen supply, by his friend on 6th April 2014.

6) Mr Day’s post-mortem showed that he had died of natural causes and that the Co-Amoxiclav had not caused an allergic reaction despite his known allergy to this drug.

(1) During the course of my investigation, I heard live evidence from ████████ who was the out-of-hours doctor who visited Mr Day. He told me that he did not have access to the ████████ medical records and that this was a common situation. He said that he had asked Mr Day if he had any allergies to medication, and Mr Day replied that he did not have any such allergies. Whilst Mr Day appeared to have capacity, the information which he gave to ████████ was incorrect, and as a consequence, ████████ prescribed Co-Amoxiclav to Mr Day.

(2) In this case, the patient did not die as a result of the medication which was prescribed, but if the patient had died, an inquest would have inevitably resulted. Moreover, the patient had capacity to give an (incorrect) answer, but if the patient lacked capacity to do so, I am concerned that the out-of-hours doctor has no way of verifying the appropriateness of the medication which he wishes to prescribe. Accordingly I am concerned that there is not a way in which out-of-hours doctors can access the “Allergies” section of a patient’s medical notes in every case. As I understand it, even if a patient opts out of the NHS Spine, the information about allergies should still be available to any medical personnel who consult the database.