Gran died during ‘urgent’ treatment wait
Coroner: Referring patient by post to hospital ‘unduly slow, cumbersome and prone to mishap’
06 October, 2017 — By Emily Finch
Coroner Mary Hassell
A GRANDMOTHER died in pain waiting for her hospital appointment after an “unduly slow, cumbersome and prone to mishap” referral system at her Newington Green dental surgery.
Bronwyn Williams, 68, from Homerton, visited Kindandental clinic, in Newington Green Road, on May 4 unable to open her jaw because of a bacterial infection.
Ms Williams had initially visited Homerton Hospital’s A&E department on May 1 complaining of pain and malaise but was referred to her dentist at Kindandental, who could not examine her mouth because of the severe lockjaw. The dentist prescribed her antibiotics alongside an “urgent” referral to an oral surgery unit at Homerton Hospital.
But in the referral her road name was spelled wrongly and the postcode omitted – mistakes which caused a delay.
An “urgent” referral meant she should have been seen by the hospital within two weeks but Ms William’s appointment was eventually scheduled for June 19 – almost a month after her death on May 23 and seven weeks after her referral.
Homerton Hospital originally scheduled her appointment for May 30 but cancelled it on the day she died and rescheduled it for the June date.
St Pancras coroner Mary Hassell has said Kindandental’s referral system is a “matter of concern”.
“I heard at inquest that the urgent referral from Kindandental to the Homerton was made not by logging on to a portal, or by email, or by fax, but by post. This seems unduly slow, cumbersome and prone to mishap,” she wrote in her prevention of future deaths report, published this week. She also raised as a “matter of concern” Ms Williams’ nearly seven-week wait for an appointment with Homerton Hospital’s oral unit.
Ms Hassell gave the cause of death as septicaemia and mediastinitis, with a secondary cause of type II diabetes mellitus.
Michael Ward, practice director at Kindandental, said the dentist in charge of Ms Williams’ treatment and referral had now left the practice because of unrelated reasons.
He said: “We were deeply saddened to hear of the death of Ms Bronwyn Williams. We accept the coroner’s comments and concerns in regard to this and have fully reviewed practice procedures for patient referral.”
A spokesman for Homerton University Hospital said: “We offer our sincere condolences to Ms Williams’ family.
“Ms Williams was directed to her dentist by our A&E clinicians as she had a dental problem which at that point they did not assess as needing immediate treatment.
“After further treatment, her dentist referred her to a specialist in oro-maxillofacial surgery at Homerton. However, dental practitioners do not have access to the electronic referral systems that GPs and other community health staff have, and have to rely on post, which creates delay and which led to some confusion about the urgency of this case.
“The lack of electronic access for dentists when they refer patients to hospital is a national issue and we are discussing it with the coroner and NHS England.”