May 2014 - case study 2

Date: 30 April 2014

  • Details:

    A terminally ill patient died at home in the early hours of the morning. The family had been previously advised that due to the patient’s particular condition, death would need to be certified by a GP as the matter would need to be notified to the Coroner, and so they called the GP out of hours service provided by EEAST. A GP visit was initially refused and the family advised that a District Nurse, due to visit, could deal with the situation. After further telephone calls, a Community Practitioner (CP) and subsequently a GP attended. The patient’s family considered that they both were rude and dismissive.

  • Findings:

    The investigation found that cases of expected death where an Inquest is required are rare and that there was confusion regarding procedures. The out of hours service will usually attend expected deaths to verify life extinct, and not to certify death, which is usually performed by the patient’s own GP. A GP or Paramedic from the 111 service should have attended in this case when requested by the family. Both practitioners stated that it was not their intention to appear abrupt and rude.

  • Lesson learnt / action taken:

    Procedures applicable to expected deaths requiring an Inquest have been clarified with the Coroner’s office. Information has been sent to all medical staff to clarify what process should be followed if they receive such a request in the future.

  • Date:
    29 April 2014