Near-fatal asthma attack

A 20-year old student attended a GP practice in the springtime with a three-week history of a cough that seemed to be worse in the evenings. She reported a previous similar episode in the preceding year. She had stopped smoking two months earlier and had a personal and family history of atopy.

She saw the nurse practitioner, who auscultated her chest and suspected that her symptoms were due to a resolving viral respiratory tract infection. Advice was given to remain off cigarettes and she was given an inhaled beta-agonist with instructions on its correct use. No comment was made in the clinical records about the possibility that her cough was a manifestation of asthma, and the history of atopy was discussed during the consultation.

Four months later the practice received a discharge notification from the local hospital. The student had been admitted via casualty with extreme difficulty in breathing, rapidly deteriorated and required ventilation. The discharge summary noted that the patient had been unaware that she had asthma and that she had been using one inhaler per week for about two weeks prior to her admission. Prior to discharge she had been seen by a chest physician who had started her on inhaled steroids and planned to follow her up for the subsequent six to 12 months.

The practice recognised that the management of the patient had been inadequate, and on reviewing her clinical records found that prescriptions for a beta-agonist inhaler had been issued seven times over the preceding four months, but this had not been picked up – in part because the patient had not been coded as suffering from asthma. In addition to flagging the matter as a patient safety incident, the partners responsible for clinical governance along with the practice manager considered whether the statutory duty of candour might apply. A senior GP who had not been involved in the patient's care (and had not signed any of the prescriptions) reviewed the records and concluded that a failure to properly assess and treat the initial presentation with asthma had contributed to the later deterioration, and that this incident was both unintended and unexpected. The fact the patient needed ventilation was judged to meet the threshold triggering the statutory duty of candour.

As soon as the senior GP had given an independent opinion as to whether the statutory duty of candour applied, the practice manager made contact with the patient, explaining that they had been alerted to the recent hospital admission and would like to speak to her about that. It was made clear during that discussion that the practice felt it could have managed her asthma better, and they were sorry for that. The patient said that she felt much improved and would happily come to speak to the practice.

A meeting was arranged with the patient, practice manager, the nurse practitioner and a senior partner. The senior partner explained that they had reviewed what happened, and realised that several things could have and should have been done differently and apologised that the asthma was so poorly controlled and that contributed to the patient's serious respiratory problem.

The nurse practitioner gave a sincere, personal apology and explained how she had thoroughly reflected on the consultation and had arranged to undertake further clinical study. The practice manager explained that under the duty of candour rules that applied to healthcare organisations, they would be providing her with a written account of their investigation into the matter, and offered to provide a formal, written apology. It was agreed by everyone that a further review was unnecessary and that lessons had been learnt.

The patient said that although she was concerned that her deteriorating condition had not been picked up, she was satisfied with what she had been told, and appreciated the personal apologies to the extent that a written apology was not needed from her perspective.

The practice manager, with input from the nurse practitioner and senior partner, drafted a note of the meeting, and incorporated that into a report summarising the investigation, its conclusions and actions it had identified – repeat asthma prescribing was overhauled and the nurse practitioner had been booked onto an asthma course. Although the patient had not required a further apology, the apologies given at the meeting were recorded in the report. The incident was later summarised in the practice's annual report.

This guidance was correct at publication 29/03/2018. It is intended as general guidance for members only. If you are a member and need specific advice relating to your own circumstances, please contact one of our advisers.

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