AN ELDERLY patient visited his GP about a recent chest pain and was given an electrocardiogram (ECG) which was misread. He was advised to go home, when he should have been sent to hospital, and died there 24-48 hours later from a heart attack.

Another elderly patient, suffering from atrial fibrillation (irregular and often rapid heart rate), was visited by his GP who prescribed medication and noted he should be referred to the district nurses for monitoring. The information in the notes was not passed on and the patient wasn’t monitored for three weeks. That person became ill, was admitted to hospital and subsequently died.

These are just a two of the most serious incidents involving patients aged over 65 in England and Wales where poor communication and other failures in the health services – primary and secondary care – led to patient harm.

Researchers at Cardiff University School of Medicine have examined nearly 1,600 patient safety reports over an eight-year period relating to people aged over 65 in England and Wales. It is the largest study of this kind using the biggest database of patient safety incident reports in the world.

The sort of incidents they discovered included misdiagnosis, inappropriate treatment, wrong drugs prescribed, wrong dosage of drugs, mistakes involving drugs that looked or sounded like the correct drugs, referrals sent to the wrong service and key information missing from referrals.

Older patients account for half of all 340 million general practice consultations in the UK each year and the research report says 170,000 older adults each year in the UK may receive care that causes death or severe physical or psychological harm.

The results of the study have been published in Age and Ageing, the scientific journal of the British Geriatrics Society, and suggests that new multidisciplinary community-based care systems with improved access to specialist geriatric advice may improve complex clinical decision-making and management of multiple serious health conditions - reducing harm to older patients.

The study recommends that local procedures within the multidisciplinary team should ensure there is an effective system of following-up patients’ medical results, especially for those patients unable to understand or make decisions about their own results.

It also says IT systems with standardised formats could reduce medication and clinical decision-making incidents, inappropriate prescribing and other drug administration incidents.

The report says: “A fifth of reports in our sample described a serious patient harm outcome. Scrutiny of the descriptions in the remainder of reports suggested that many could have escalated into more serious outcomes if healthcare professionals or relatives had not intervened.”

Worcestershire has an above average elderly population and many are unable through illness or frailty to manage their own health care or question medical decisions/interventions. They rely on health professionals. Many elderly people also have to cope with multiple health conditions which are difficult to understand.

Dr Andrew Carson-Stevens, Patient Safety Research Lead at the Primary and Emergency Care Research Centre at Cardiff University School of Medicine, and author of the Age & Ageing paper, said: “Safe, high quality care is delivered in primary care every day. However, patient safety incident reports provide us with a means of learning about what changes could be needed and how we might go about designing safer systems of care delivery for older patients.

“The study highlights weaknesses in the current healthcare system that must now form the basis of further research and improvement activity. As more older adults are being treated in community settings, healthcare systems must be designed to meet the needs of the population served.”