Man with breathing problems found dead in home after GP practice asked patients to email instead of calling – and his message went unanswered for three days

A senior coroner has warned the government that GP surgeries are asking patients to email instead of calling after a man died because staff ignored him.

Allan Hamilton was having trouble breathing when he emailed for help on November 14. During previous visits to his GP, he had been told not to call for help.

However, his email was ignored for three days and on November 19, he was found dead in his home of pneumonia and heart disease.

Alison Mutch, a senior coroner in Manchester, said his death was preventable. She wrote to the Department of Health in what is known as the Prevention of Future Deaths Report.

Alison Mutch, a senior coroner in Manchester, has produced a report on preventing future deaths

In her letter, Ms Mutch wrote: ‘In the case of Mr Hamilton, effective investigation of his query, follow-up contact with his GP on 14 November and medical advice would probably have prevented him from dying at the time.’

The inquest into his death heard that the GP, owned by SSP Health, based in the north-west of England, had moved to a system where contact was encouraged ‘electronic’.

More importantly, the investigation found that the electronic system the clinic used had no way to track and rank emails based on their importance.

Ms Mutch concluded: ‘The practice had no system in place to track email queries such as those from Mr Hamilton and there was no clear system for sorting emails such as his.’

An ‘effective’ electronic communications system only works if there is a ‘clear and robust process’ for monitoring patient contacts, the coroner said.

Ms Mutch said there also needs to be a ‘clear audit trail’ and ‘effective triage’ by medically qualified team members.

Her report was handed to the Department of Health and Social Care and SSP Health. Both organisations have 56 days to respond to her request.

“I believe that action must be taken to prevent future deaths and I believe you have the power to take such action,” Ms Mutch added.

It was not until July that an investigation by the Health Services Safety Investigations Branch (HSSIB) revealed shortcomings in the move to online communications.

In a number of cases, the Prevention of Future Death Reports noted online consultations as opposed to physical meetings.

In a summary of the report, the authors concluded: ‘There are concerns that these devices may contribute to patient safety incidents.

‘The future of healthcare includes technology that can deliver care, but we must take into account potential risks to patient safety.’