Boy's death 'shows hospitals need access to GP notes'

A coroner is calling for hospitals to be able to access GP records after a four-year-old boy died from a brain tumour.

Hassan Shah, assistant coroner for Northamptonshire, found Akhona Moyo's death could have been prevented if he had received "earlier intervention".

He said Akhona, from Northampton, died in November 2022, three days after he was admitted to hospital. He "probably would have survived" if pressure on his brain had been reduced earlier, the coroner said.

The coroner's prevention of future deaths report has been sent to the secretary of state for health and social care, Northampton General Hospital and NHS England.

In a narrative conclusion on 27 January, the inquest heard Akhona died from acute obstructive hydrocephalus and posterior fossa ependymoma at Queen's Medical Centre, Nottingham, on 26 November 2022.

Shah said: "Had he been admitted to hospital on 23 November 2022, scanned earlier in the day on 24 November 2022 and received earlier intervention directed at reducing intracranial pressure, he probably would have survived."

The report said hospital doctors did not have electronic access to primary care medical notes, including GP and community mental health notes, and an electronic system at Northampton General Hospital only contained hospital notes.

Notes hospitals can access only contained "basic lists of GP visits and medication, but no detailed entries", the report said.

The coroner said all the doctors who gave evidence at the inquest had said access to primary care records would have assisted them in "delivering better patient treatment and care".

"There may be a multitude of other reasons why a patient or their family may not be able to relay to doctors a full and accurate medical history," said the coroner.

Access may also enable doctors to have a more global view of a patient's medical condition rather than, as it was put at inquest, "working in silos"."

All three organisations have until 24 March to respond.

Hemant Nemade, University Hospitals of Northamptonshire medical director, said: "We are deeply sorry that we did not offer an earlier scan to affect this tragic outcome.

"A significant programme of work is ongoing across our hospitals to ensure that the learning from this case is fully understood and translated into meaningful improvements in patient care, so that we reduce the risk of this happening again."

A Department of Health and Social Care spokesperson said: "We are committed to responding to and learning from all prevention of future deaths reports and will consider this report in full before formally responding."

An NHS England spokesperson said it "extends its deepest sympathies to the parents and family of Akhona Moyo".

"We are carefully considering the prevention of future deaths report sent to us by HM Coroner and will respond in due course."

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