Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0247, written 26 Jun 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 26 Jun 2015 |
|---|---|
| Reference | 2015-0247 |
| Deceased | Alec Mathias |
| Coroner | Elizabeth Earland |
| Coroner area | Exeter and Greater Devon |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.
ANNEX A REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 4. Chief Executive of the Royal Devon and Exeter Hospital 2. - 3. - 4 | CORONER 1 am Dr Elizabeth Earland Senior Coroner for the coroner area of Exeter and Greater Devon. 2 | CORONER’S LEGAL POWERS | make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 3. | INVESTIGATION and INQUEST On 7" October 2014 | commenced an investigation into the death of Alec James MATHIAS, 78 years old. The investigation concluded at the end of the inquest on 24" June 2015. The conclusion of the inquest was Misadventure with the Cause of Death of being — 1a — Liver Failure 4b —Flucloxacillin Induced Cholestatic Liver Injury 4c — Treatment for Cellulitis of the Left Index Finger Il — Radiation Proctitis following Radiotherapy for Carcinoma of the Prostate 4 | CIRCUMSTANCES OF THE DEATH Mr Mathias suffered from a whitlow of his Left Index Finger in June/July 2008 during which time he was treated with Flucloxacillin. He was admitted to the Royal Devon and Exeter (Wonford) Hospital on the 10" September 2008 with a presumptive diagnosis of painless obstructive jaundice under I HE following a GP letter dated 9" September 2008 t Consultant Gastroenterologist (see p.4 statement off HE dated 29.01.2015). It was found that he had suffered drug induced jaundice and the Flucloxacillin was stopped (further doses having been given while he was an in-patient). There is no record of a discharge summary being sent to Mr Mathias’s GP or that he had suffered a reaction to the Flucloxacillin and that this had been the agreed cause of his liver probiems. Mr Mathias suffered further infection of the index finger in August 2014 and was again prescribed Flucloxacillin by the GP practice nurse, which proved fatal — see Record of Inquest. . | received evidence fro ZEEE c September 2008 admission and I and iE regarding the 22" August 2014 admission and it is clear that not only was no discharge letter sent to the GP in 2008 alerting the practice to Mr Mathias's idiosyncrasy regarding Flucloxacillin but there was no highlighting of the hospital notes that he had an allergy or would suffer a reaction if given Flucioxacillin. The administration of Flucloxacillin has caused Mr Mathias’s death. CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. — (1) Discharge letters have not been sent to the patients GP in a case where a dangerous side effect to treatment has been noted (2) That the hospital has not highlighted its own records with vital information on drug sensitivity discovered and diagnosed on an in-patient. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you have the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 21° August 2015. |, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner. lam also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coraner. 26" June 2015 [SIGN ONER’ wi
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