‘Patient died after GP surgery took three days to respond to email’

A coroner has warned the Department of Health and Social Care (DHSC) and SSP Health to take action to improve GP electronic triage systems, following the death of a patient.

Allan Robin Hamilton died of lobar pneumonia in November 2023 after a request for advice from his GP practice was not actioned until three days after it was sent to them.

On 14 November 2023, Hamilton emailed his GP surgery indicating he was having breathing difficulties and seeking advice.

The surgery, which is run by GP practice group SSP Health, responded on 17 November 2023, asking if he still required an appointment.

Hamilton was found unresponsive at his home on 19 November 2023.

In a prevention of future deaths report, published on 23 August 2024, Alison Mutch, senior coroner for South Manchester, said: “In Mr Hamilton’s case effective scrutiny of his query and follow up contact from his GP on 14/11 and medical advice would probably have meant he would not have died when he did.”

Mutch added: “Like many GP practices the surgery in question had moved to a system where contact was  encouraged electronically.

“The surgery had no system for tracking email queries such as the one sent by Mr Hamilton and there was no clear system for triage of emails such as the one he sent.”

She said that the inquest heard evidence that “an electronic system of patient referrals is only effective if there is a clear and robust process for checking regularly for patient contacts, a clear audit trail and effective triage by medically qualified members of the team”.

Mutch stated that in her opinion, there is a risk that future deaths will occur unless action is taken.

“The inquest heard evidence that there was a risk of a similar situation arising if GP practices do not have clear and robust triage and audit processes in place,” she said.

SSP Health and DHSC have until 18 October 2024 to respond to the report.

Andy Scaife, chief executive of SSP Health told Digital Health News: “We are deeply saddened at the death of one of our patients. Our thoughts and heartfelt condolences are with the Mr Hamiton’s family and loved ones during this difficult time.

“We understand that, due to the coroner’s report, there are concerns regarding the circumstances surrounding this unfortunate case. We are currently conducting a thorough internal review to understand the exact circumstance, which will include a review of the accuracy of certain aspects of the report”.

He added that SSP Health is preparing its own report which will detail its findings and correct any inaccuracies.

A spokesperson for DHSC said: “Our deepest sympathies are with Allan Hamilton’s family and friends in this tragic case.

“Patient safety is a top priority and this government is committed to fixing the front door to the NHS”.

In July 2024, the Health Services Safety Investigations Body a report on its investigation, which found that patient safety incidents relating to the use of online consultation tools by GPs have been underreported.