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Lessons Learnt

The LMC have been asked to share some lessons learnt from recent Serious Incidents which have affected Lincolnshire patients.

Missed diabetes in a child

A parent contacted a surgery using an online consultation platform advising that her child had started to wet the bed after having been “dry” for four years. The mother was offered a routine appointment a few days later, but the child went into ketoacidotic coma and was admitted to hospital before the appointment.

The lessons learnt were

- online consultations for children with new symptoms should prompt the clinician to consider telephone or face-to-face consultation rather than delayed appointment

- children with change in urinary symptoms always require urine dip testing to exclude UTI or new onset diabetes

Un-healing wounds

A patient had surgical intervention and had the wound dressed by community team on discharge. The patient then presented a number of times to the community team, GP practice, minor injuries, and A&E, with problems with the wound. The patient had multiple courses of antibiotics, but the wound did not heal. Subsequent referral to Tissue Viability Nurse revealed a retained surgical swab.

The lessons learnt were

- repeated consultations for the same problem which does not resolve should prompt the clinician to consider onward referral for specialist advice

- un-healing wounds do not respond to oral antibiotics, as there is usually another cause for the wounds to not heal, and thus TVN referral should be considered early

Hospital administered medications

Patients who are on medication which is administered by specialist teams in hospital, such as; disease modifying anti-rheumatoid drugs (DMARDSs), biological agents, and antipsychotics, have been involved in significant events because clinicians in community settings did not know that these patients were being given these drugs. The GP practices had been informed that these drugs were being administered, but the practices did not have a process in place to record this in the patient record.

The lessons learnt were

- GP practices need to identify from hospital correspondence when patients are started on medications which will be administered by hospital clinicians

- GP practices should have a system in place to ensure that these medications are added to the patient’s medical record as “hospital administered” drugs. A guide for how to do this is attached above to view and download.

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