Paper records a ‘direct factor’ in patient’s death

An independent inquiry into the death of a patient seen by eight different doctors over a bank holiday weekend has concluded that the paper-based system of record keeping used by the out-of-hours service was a direct factor in the patient’s death.

Penny Campbell, a journalist, died after a series of doctors from the Camidoc out-of-hours (OOH) service in north London failed to diagnose that she was suffering from septicaemia following an injection for haemorrhoids.

The inquiry found that at the time Campbell came into contact with Camidoc over the bank holiday weekend in March 2005 the system for recording clinical notes was paper based. Although notes were kept, reviewed and stored, retrieval was a major problem and all the doctors involved did not have easy access to her previous consultations.

The report by a team of independent investigators concluded: “The failure to ensure that notes were available was a major system failure and a direct factor leading to Penny Campbell’s death.”

The investigators’ report said that the risks inherent in the paper-based system had not been properly assessed. It added: “The unwieldiness of the system and its unpopularity with the clinicians was a fact known to the Camidoc board.”

The report acknowledges that Camidoc acted rapidly to upgrade the clinical records system, provided by Adastra, to a fully computerised version after Penny Campbell’s death and that details of previous patient consultations are now available to Camidoc doctors on the computer systems.

The report, delivered to the four London PCTs that commission Camidoc, recommended that the OOH service should improve its organisational governance and ensure that it has appropriate systems in place to monitor and improve quality and safety. The PCTs were advised to recognise the importance of the service and develop action plans to respond to the findings of the investigation.

The inquiry panel also recommended that all OOH providers and commissioners should consider the implications of the case for their own organisations. It said that the Department of Health should clarify national expectations of the role and performance of our of hours services and that policy confusion over whether an OOH service is for urgent or unscheduled care should be addressed.

Following publication of the report Camidoc issues a statement reiterating its sympathies to Campbell’s family. It added: “We accept and will deliver all of the recommendations many of which we are already in the process of implementing. The report acknowledges the significant progress Camidoc has made in upgrading technology and implementing enhanced procedures since March 2005.”

Rachel Tyndall, chief executive of Islington PCT, said the trust was determined to learn the lessons of the Campbell case.

She added: “We are committed to working closely with Camidoc and the other commissioning PCTs to ensure that out-of-hours care has efficient clinical systems in place to guarantee high quality care that is responsive to the needs of patients. A case like this must never happen again.”

The DH said it had already asked PCTs to review their use of paper-based systems in out-of-hours care. 

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