NHS 24 faces legal action over patient deaths

NHS 24, the Scottish health helpline service, is being sued for £750,000 damages by the partner of a man who died of toxic shock. Kerry Robertson is claiming that the helpline’s neglect contributed to the death of 30 year-old Steven Wiseman.

It is the first time that the helpline service has been sued for medical neglect. It is also thought to be the first time that the design and use of NHS software will be at the centre of a legal action in a UK court over the death of a patient.

Wiseman died in December 2004. Robertson, who had two children with him, called NHS 24 three times over three days before his death. Despite being informed that her partner was complaining of severe shoulder pains and displaying symptoms of jaundice, staff at the NHS 24 Aberdeen call centre told Robertson that Wiseman was suffering from flu, and should take paracetamol.

Her legal action against NHS 24 is likely to be joined by a second action by the family of Shomi Miah.

The 17 year old student from Aberdeen died of meningitis in October 2004 after NHS 24 failed to diagnose her symptoms. Her family rang the helpline twice, reporting that she was complaining of acute headaches, stiffness in her neck and aching arms and legs, and could not move from her bed.

Miah had suffered from meningitis previously in 1996, and the immediate concern of her father and brothers was that she was suffering another bout of the disease. In both calls to NHS 24, they repeatedly stated their concern that she was suffering from meningitis. Staff at the same Aberdeen call centre dismissed this possibility and told them that she was suffering from flu-like symptoms, and should take paracetamol.

The procurator fiscal, Scotland’s senior law officer, was so concerned about the two deaths that he ordered a fatal accident inquiry into both cases.

The judge presiding over the inquiry, Sheriff Tierney, placed the design and use of computer software at the centre of his inquest. “The question is,” he wrote in his final report “whether that system was adequate to meet the needs of Shomi Moshina [Miah] and Steven Wiseman and, if it was, whether it was operated properly and safely in each case.”

The judge’s published report into the two cases is likely to form the basis for Robertson’s action against NHS 24, and any action taken by Miah’s family.

The judge found in the cases of both Wiseman and Miah that “questioning by nurses in furtherance of the [computer] algorithms was superficial with the result that obvious questions were not asked, closed or leading questions were asked, assumptions were made, full information was not obtained from the patient and potentially dangerous conditions were not identified.”

He found there was confusion amongst staff using the computer systems over the extent to which they could disregard the software’s recommendations: “No clear guidelines or instructions were issued to nurse advisors as to the extent to which algorithms or protocols should be followed and the extent to which a nurse was entitled to exercise his or her clinical judgement not to follow an outcome brought about by use of the algorithm.”

The software adopted by NHS 24 has been in use in the United States and in England for at least a decade. This version was described by the judge as “highly prescriptive”. However, before adopting the software in Scotland, the Scottish NHS held a review of the computer algorithms chaired by a GP, Dr Bryan Robson. This resulted in the computer algorithms being adapted and made far less prescriptive. According to the judge, the computer algorithms in Scotland were altered to become a series of “prompts” that did not have to be “rigidly followed in all circumstances.”

Following this software review, Dr Robson was then appointed as the medical director of NHS 24.

In giving evidence, one of the nurse advisors who had handled the Miah calls told the inquiry that it “was not necessary to ask every question on the algorithm” but that she “used her clinical assessment skills to ask the appropriate questions to bring to light possible symptoms.” The other nurse advisor was said to be suffering from fatigue and stress, and did not appear before the public inquiry.

Dr Diarmid Kennedy, a consultant in infectious diseases who has lectured at Glasgow and Yale universities, appeared at the inquiry to provide expert testimony on the handling of the calls, and the accuracy of the clinical record recorded by the nurse advisors.

He was critical of the way all the calls had been conducted. He felt that the initial calls should have triggered immediate concern, and that both lives were saveable if the calls had been conducted differently. Dr Kennedy also criticised the adapted algorithms used by NHS 24, stating that as a consultant specialist, he believed they did not accord enough diagnostic weighting to rigors as a symptom of meningitis.

He also stated that he felt the call records on the computer system did not reflect accurately the actual conversations recorded in the call transcripts. In his view, the severity of Miah’s condition in particular had been significantly misrepresented in the computer-based clinical record.

Dr Robson, NHS 24 medical director, was questioned over Dr Kennedy’s criticisms of the adapted algorithms employed by NHS 24. He stated that the Scottish algorithms had been developed in consultation with GPs, not with specialists in the clinical specialties. He defended the way that his committee had reviewed the algorithms, and stated that he did not “think it appropriate that the algorithm be reviewed by consultants in the field.”

Whilst he accepted that someone in Dr. Kennedy’s position might be a useful addition to the team in drafting the algorithm, he did not feel that the absence of such a person meant that there was a gap in the protocol.

Link 

Fatal accident inquiry concerning the deaths of Shomi Moshina and Steven Alexander Wiseman