Thomas Rawnsley inquest: Coroner calls for out of hours assessment changes

Thomas Rawnsley, from Bradford, died in February 2015

A coroner has called for changes to the way out-of-hours GPs assess patients.

Thomas Rawnsley, 20, from Bradford, died on 4 February 2015, two days after suffering a heart attack as a result of a chest infection.

A GP who gave advice over the phone after Mr Rawnsley vomited was apparently unaware of the infection.

Assistant South Yorkshire coroner Abigail Combes urged NHS England to issue a standardised set of questions to medics.

An inquest into his death heard his carers at Kingdom House, Sheffield, had called 111 on the night of 1 February asking for advice when he vomited shortly after taking medication for the infection and whether to re-administer the drugs.

In Ms Combes' Prevention of Future Deaths report she said the 111 call handler had asked a standardised series of questions before passing the matter on to the out-of-hours GP.

However, she said, the GP "did not take any history" and did not access Mr Rawnsley's record.

He was therefore unaware the patient had a chest infection when he gave clinical advice, she said.

The inquest heard Mr Rawnsley collapsed the following morning and was taken to hospital.

Mr Rawnsley's mother, Paula, said she was pleased some changes may be made following her son's death

The coroner said: "Without a standard set of initial questions asked it is entirely possible that clinicians will provide advice in isolation of other important matters.

"This could be as simple as current medications that the patient routinely takes or current diagnosis the patient has which impact upon the advice to be provided.

"This may lead to incomplete or worse, inappropriate advice being given to patients during a clinical triage."

The coroner also called for Yorkshire Ambulance Service (YAS), who were called to see Mr Rawnsley on 29 January, to consider an audit of written information given out by paramedics to patients and their carers.

The inquest, which ended last November, concluded Mr Rawnsley died as a result of natural causes.

His mother, Paula, who has previously criticised the scope of the inquest, said she was pleased "at least some changes" may be made but said she was "angry" no further recommendations had been made in relation to her son's care and treatment.

A spokesperson for YAS said it had taken steps to strengthen procedures highlighted by the coroner and planned to carry out the recommended audit.

NHS England has been approached for comment.