AN ELDERLY patient visited his GP about a recent chest pain and was given an electrocardiogram (ECG) which was misread. He was advised to go home, when he should have been sent to hospital, and died there 24-48 hours later from a heart attack.

Another elderly patient, suffering from atrial fibrillation (irregular and often rapid heart rate), was visited by his GP who prescribed medication and noted he should be referred to the district nurses for monitoring. The information in the notes was not passed on and the patient wasn’t monitored for three weeks. That person became ill, was admitted to hospital and subsequently died.

These are just a two of the most serious incidents involving patients aged over 65 in England and Wales where poor communication and other failures in the health services – primary and secondary care – led to patient harm.

Researchers at Cardiff University School of Medicine have examined nearly 1,600 patient safety reports over an eight-year period relating to people aged over 65 in England and Wales. It is the largest study of this kind using the biggest database of patient safety incident reports in the world.

The sort of incidents they discovered included misdiagnosis, inappropriate treatment, wrong drugs prescribed, wrong dosage of drugs, mistakes involving drugs that looked or sounded like the correct drugs, referrals sent to the wrong service and key information missing from referrals.

Older patients account for half of all 340 million general practice consultations in the UK each year and the research report says 170,000 older adults each year in the UK may receive care that causes death or severe physical or psychological harm.

The results of the study have been published in Age and Ageing, the scientific journal of the British Geriatrics Society, and suggests that new multidisciplinary community-based care systems with improved access to specialist geriatric advice may improve complex clinical decision-making and management of multiple serious health conditions - reducing harm to older patients.

The study recommends that local procedures within the multidisciplinary team should ensure there is an effective system of following-up patients’ medical results, especially for those patients unable to understand or make decisions about their own results.

It also says IT systems with standardised formats could reduce medication and clinical decision-making incidents, inappropriate prescribing and other drug administration incidents.

The report says: “A fifth of reports in our sample described a serious patient harm outcome. Scrutiny of the descriptions in the remainder of reports suggested that many could have escalated into more serious outcomes if healthcare professionals or relatives had not intervened.”

Worcestershire has an above average elderly population and many are unable through illness or frailty to manage their own health care or question medical decisions/interventions. They rely on health professionals. Many elderly people also have to cope with multiple health conditions which are difficult to understand.

Dr Andrew Carson-Stevens, Patient Safety Research Lead at the Primary and Emergency Care Research Centre at Cardiff University School of Medicine, and author of the Age & Ageing paper, said: “Safe, high quality care is delivered in primary care every day. However, patient safety incident reports provide us with a means of learning about what changes could be needed and how we might go about designing safer systems of care delivery for older patients.

“The study highlights weaknesses in the current healthcare system that must now form the basis of further research and improvement activity. As more older adults are being treated in community settings, healthcare systems must be designed to meet the needs of the population served.”

The Age & Ageing paper can be viewed by visiting https://academic.oup.com/ageing/article-abstract/doi/10.1093/ageing/afx044/3572914/Sources-of-unsafe-primary-care-for-older-adults-a?redirectedFrom=fulltext

Chief operating officer of Healthwatch Worcestershire Simon Adams said: “We would absolutely identify with the issues that are in the report. The NHS in Worcestershire has plans to improve that and we are seeing some changes.

“It is not uncommon that GPs do not receive letters from consultants or people turn up for a consultant appointment but the consultant does not have all the information they need.”

He said one of the major issues is that different healthcare organisations in Worcestershire do not have access to the same IT system and sharing information is therefore a problem.

“It is something they are trying to address locally. If you had a stroke, you would be taken by the ambulance service to an acute trust hospital and you would probably be discharged to a stroke bed in the health and care trust at Evesham hospital. Or you might be discharged under the care of your GP into a care home. It will involve a number of different health organisations. There is no common IT platform and no-one is in a position to share information easily.”

“All across Worcestershire, the GPs use Emis system. Hats off to them that they all came together and said they would all use the same system.

“There is work underway and our message is that patients need to be involved in that and patients need to help shape the delivery of the services in the future.”

He said Worcestershire should get credit for the work it is doing to try and resolve these issues and that is not the case everywhere. However he added that some other areas are ahead of Worcestershire and have better systems in place.

A spokesman for Worcestershire Health and Care NHS Trust said: “There is a huge amount of work going on locally across the health and social care system to address some of the issues we know exist when our vulnerable patients require the input and support of different professionals, often employed by different organisations using different ‘communication’ and IT systems.

“When speaking to people, they often share their frustrations that this situation leaves them having to repeat their ‘story’ over and over again, and overall can lead to care which is disjointed.

“We are developing Local Neighbourhood Teams which are designed to provide better all-round care to those in local communities deemed to be more vulnerable or at greater risk of being admitted to hospital.

“The teams will be made up of those staff typically involved in the care of those people like social care staff, district nurses, GPs, promoting independence teams and enhanced care teams. While these staff will continue to be employed by their respective organisations, they will work together as one team so there is lots of work going on to remove those organisational barriers.

“One of the key enablers to this is IT, and we have developed, in-house, a new IT system which will enable all those different professionals who make up a Local Neighbourhood Team to see the same up-to-date patient record. The team will use this information to plan and co-ordinate the care they provide to someone at home.”

These teams will be managed by alliance boards and Dr Jonathan Thorn, Chair of the South Worcestershire Alliance Board, said: “The development of Local Neighbourhood Teams is about providing much more responsive, proactive care out of hospital to those patients who we know are more vulnerable or frail.

“By bringing together different professionals and skills, the teams will be able to more effectively manage those people, supporting them to live well at home for as long as possible. This will deliver real benefits for patients and will help alleviate the issues and frustrations we know can exist, especially for those who have multiple conditions which require support from different professionals and teams.”

An extract from a recent document on the alliance developments says: “We recognise the way we currently organise and deliver services can result in care being fragmented - leading to duplication at best and gaps in care at worst.

“Our goal is to remove boundaries at the point that care is delivered, to create a system where resources are collectively focused on improving health outcomes, supporting people to stay well and to live independently for as long as they wish.”