"Missed opportunity" - Chesterfield woman, 30, died on Christmas Day after GP's IT-system glitch

By Oliver McManus
Published 27th Apr 2023, 14:16 BST
Updated 2nd May 2023, 09:29 BST
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A Chesterfield woman died after a GP system glitch meant she wasn’t informed about a medical condition she had.

Jade Revell was admitted to Chesterfield Royal Hospital on December 25 2021 after suffering a sudden cardiac event at her home address. Despite extensive resuscitation she passed away in hospital on the same day.

Jade, 30, who suffered with an eating disorder, was under the care of the mental health team and had her bloods tested prior to a change of medication earlier in the year. The result showed a low potassium level which ‘required further action’ and were sent to her GP practice on October 27.

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A newly published prevention of future deaths report – prepared by Derby and Derbyshire’s assistant coroner Sarah Huntbach – concluded that “there was a failure to notify Jade of this result. This caused a missed opportunity to medically treat the hypokalaemia and monitor the potassium levels which increased the risk of ventricular fibrillation and sudden cardiac death” and this missed opportunity ‘more than minimally’ contributed to her death.

A newly published prevention of future deaths report – prepared by Derby and Derbyshire’s assistant coroner Sarah Huntbach – concluded that “there was a failure to notify Jade of this result. This caused a missed opportunity to medically treat the hypokalaemia and monitor the potassium levels which increased the risk of ventricular fibrillation and sudden cardiac death” and this missed opportunity ‘more than minimally’ contributed to her death.A newly published prevention of future deaths report – prepared by Derby and Derbyshire’s assistant coroner Sarah Huntbach – concluded that “there was a failure to notify Jade of this result. This caused a missed opportunity to medically treat the hypokalaemia and monitor the potassium levels which increased the risk of ventricular fibrillation and sudden cardiac death” and this missed opportunity ‘more than minimally’ contributed to her death.
A newly published prevention of future deaths report – prepared by Derby and Derbyshire’s assistant coroner Sarah Huntbach – concluded that “there was a failure to notify Jade of this result. This caused a missed opportunity to medically treat the hypokalaemia and monitor the potassium levels which increased the risk of ventricular fibrillation and sudden cardiac death” and this missed opportunity ‘more than minimally’ contributed to her death.

The coroner highlighted two areas of concern that TPP Ltd, the company behind the computer programme, should taken action about in order to similar future deaths.

The report reads: “The SystemOne computer programme used by the GP Practice can, when a clinician is reviewing the results (blood) from the laboratory with the screen in minimised mode (which is not unusual because of a need to work with a split screen), not show all the results.

"To do so would need the clinician to scroll down and a scroll feature is not available. This gives rise to the risk of an abnormal result being missed and unactioned.“Abnormal (out of range) should be more visable – appear at the top of a list and colour coded to minimise the risk of a result not being seen / missed. The computer programme prevents this.”

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Failures of the system included the inability for a clinician to scroll down to review results when the screen is minimised or being viewed as part of a split-screen set up.

TPP Ltd has been approached for comment.

Related topics:ChesterfieldChesterfield Royal HospitalDerbyshire