Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0113, written 18 Mar 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 18 Mar 2016 |
|---|---|
| Reference | 2016-0113 |
| Deceased | Rubana Pathan |
| Coroner | Mary Hassell |
| Coroner area | Inner North London |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Homerton University Hospital NHS Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: Prevention of Future Deaths report
Rubana PATHAN (died 21.11.15)
THIS REPORT IS BEING SENT TO:
1.
2.
Medical Director
Homerton University Hospital NHS Trust
Homerton Row
London E9 6SR
Medical Director
Johnson & Johnson Medical Devices
Pinewood Campus
Nine Mile Ride
Wokingham
Berkshire
RG40 3EW
1
CORONER
I am: Coroner ME Hassell
Senior Coroner
Inner North London
St Pancras Coroner’s Court
Camley Street
London N1C 4PP
2
CORONER’S LEGAL POWERS
I make this report under the Coroners and Justice Act 2009,
paragraph 7, Schedule 5, and
The Coroners (Investigations) Regulations 2013,
regulations 28 and 29.
3
INVESTIGATION and INQUEST
On 25 November 2015, one of my assistant coroners, Richard Britain,
commenced an investigation into the death of Rubana Pathan, aged 40
years. The investigation concluded at the end of the inquest earlier today.
I made a determination as follows.
1
Rubana Pathan died as a consequence of a rare but recognised
complication of medical treatment, being a staphylococcal aureus
infection of her breast implant wound. (Breast reconstruction following a
mastectomy undertaken to treat breast cancer.)
4
CIRCUMSTANCES OF THE DEATH
Ms Pathan was admitted to Homerton University Hospital on Thursday, 5
November 2015 and was immediately recognised to be potentially very
unwell. Her breast reconstruction wound later grew staphylococcus
aureus, she was found to be positive for the TSST-1 gene, and was
diagnosed with toxic shock syndrome.
I recorded a medical cause of death of:
1a toxic shock syndrome
1b staphylococcus aureus infection
1c infected breast implant wound
5
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.
Although Ms Pathan’s MENTOR breast implant was suspected as being
the cause of her sepsis and was removed on the evening of Saturday, 7
November 2015, her surgeon told me at inquest that she still did not
believe this to be the cause, because she found no pus or localised
redness.
However, one of the treating microbiologists undertook a literature search
after Ms Pathan’s death and discovered that the toxin found to be
responsible for her illness can supress signs of local inflammation such
as the production of pus.
Although this is a rare occurrence, it seems to me that the information
could usefully be disseminated among those likely to be caring for
patients who may be at risk of developing sepsis, both by the hospital and
by the implant manufacturer.
6
ACTION SHOULD BE TAKEN
2
In my opinion, action should be taken to prevent future deaths and I
believe that you have the power to take such action.
7
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date
of this report, namely by 23 May 2016. I, 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.
8
COPIES and PUBLICATION
I have sent a copy of my report to the following.
HHJ Peter Thornton QC, the Chief Coroner of England & Wales
Professor Dame Sally Davies, Chief Medical Officer for England
Medicines and Healthcare Products Regulatory Agency
surgeon, Homerton University Hospital
, microbiologist, Homerton University Hospital
husband of Rubana Pathan
I am 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
interest. You may make
he believes may
representations to me, the Senior Coroner, at the time of your response,
about the release or the publication of your response by the Chief
Coroner.
it useful or of
find
9
DATE SIGNED BY SENIOR CORONER
18.03.16
3
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Homerton University Hospital Trust Offices Education Centre Homerton Row London E9 6SR Tel: 020 8510 7244 www.homerton.nhs.uk 25th May 2016 Coroner Mary Hassell Senior Coroner Inner North London St Pancras Coroner’s Court Camley Street London, N1C 4PP By email to Coroner’s office: Dear Coroner Hassell, Re: Prevention of Future Deaths notice in relation to Staphylococcal Toxic Shock Syndrome Thank you for the email sent on 21st March, which contained a Prevention of Future Deaths notice in relation to the care of Mrs Rubana Pathan. As you know, Mrs Pathan sadly died on 21st November 2015 from Staphylococcus aureus Toxic Shock Syndrome following breast implant surgery. In the PFD, you requested that we disseminate information about this particular and rare manifestation among our clinicians who are responsible for caring for patients who are at risk of developing sepsis. I am writing to confirm the actions undertaken in response by Homerton University Hospital. 1. I requested that , the microbiologist who gave evidence at the inquest, perform an evidence and literature search on surgical site Staphylococcal Toxic Shock Syndrome, with particular reference to suppression of pus formation resulting in benign-looking wounds. 2. I have highlighted the need to have a high index of suspicion for sepsis associated with Staphylococcal Toxic Shock Syndrome, and shared doctors in the Trust by email. detailed literature search, with all 3. The case will be discussed in detail at a Hospital Grand Round, in order to ensure that the organisation learns as much as possible from this sad occurrence. The Grand Round was scheduled to take place on 26th April, but unfortunately had to be postponed due to the junior doctors’ industrial action which took place that day, so will take place on 28th June. 4. The Trust has directed particular focus on encouraging early recognition and treatment of patients with sepsis, as part of its Improving Quality programme. In Quarter 4 of 2015-16 we were extremely pleased that all patients admitted to Homerton with severe sepsis received antibiotics within one hour. In 2016/17, we are broadening the focus of this programme, seeking to improve the recognition, escalation and treatment of patients on our in-patient wards with potential sepsis. Incorporating hospital and community health services, teaching and research - 2 - I do hope that this provides assurance that we have taken appropriate action in response to the PFD notice. Please do not hesitate to contact me if you require any further information. Yours sincerely, Medical Director Homerton University Hospital Incorporating hospital and community health services, teaching and research
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