Man with breathing difficulties was found dead at home after GP surgery told patients to email rather than phone – and his message went unanswered for three days

A senior coroner has written a warning to the government over GP surgeries asking patients to email in rather than call after a man died when staff ignored him.

Allan Hamilton was struggling to breath when he emailed for help on November 14, having been told not to ring for assistance on previous visits to his GP.

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

Alison Mutch, a senior coroner in Manchester, said his death was avoidable and has written to the Department of Health, in what is known as a ‘Prevention of Future Deaths Report’.

In her letter, Ms Mutch says: ‘In Mr Hamilton’s case effective scrutiny of his query and follow-up contact from his GP on November 14 and medical advice would probably have meant he would not have died when he did.’ 

An inquest into his death heard the GP, owned by SSP Health, based in the North West of England, had moved to a system whereby their contact was ‘encouraged electronically’.

But crucially, the inquest found the electronic sysytem used by the clinic had no means of track and ranking emails according to their importantance.

Ms Mutch found: ‘The surgery had no system for tracking email queries such as the one sent by Mr Hamilton and there was no clear system for triage of emails such as the one he sent.’

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

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

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

‘In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action,’ Ms Mutch added.

Only in July, an investigation by the Health Services Safety Investigations Branch (HSSIB) exposed failings with the shift to online communication. 

Online consultations, as opposed to in person meetings, were in a number of instances found to have been mentioned in Prevention of Future Death Reports. 

In a summary of the report, its authors found: ‘There are concerns that these tools could contribute to patient safety incidents. 

‘The future of healthcare includes technology to help deliver care, but this needs to be done with recognition of any potential risks to patient safety.’