Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0242, written 29 Jun 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 29 Jun 2016 |
|---|---|
| Reference | 2016-0242 |
| Deceased | Peter Rowe |
| Coroner | Andrew Bridgman |
| Coroner area | Manchester South |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Central Manchester University Hospitals NHS Foundation Trust |
| 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.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1)
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
1. Sir Michael Deegan, Chief Executive, Central Manchester University
Hospitals NHS Foundation Trust, Manchester Royal Infirmary, Oxford
Road, Manchester M13 9WL.
1 | CORONER
| am Andrew Bridgman, Assistant Coroner, for the coroner area of Manchester South.
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 11th February 2016 an investigation was commenced into the death of Peter Arthur
Rowe who died while an in-patient at Stepping Hill Hospital, Stockport on 8” February
2016, having been admitted on 1* February 2016.
The investigation concluded with an Inquest held on 8" June 2016.
Medical cause of death la) Multi-organ failure
Ib) Sepsis
Ic) Toxic epidermal necrolysis
ll Psoriasis
Cerebrovascular accident
In answer to the questions ‘how, when and where’ the findings were as follows,
On the 26" January 2016 Peter Arthur Rowe was admitted to Manchester Royal
Infirmary for day case general anaesthesia for removal of a lipoma from his back. Co-
amoxiclav was administered as a prophylactic antibiotic, notwithstanding the GP referral
letter stated a penicillin allergy as of 2004. Mr and EE stated that they were
unaware of any allergies upon being asked that specific question in the pre-operative
consultations and assessments. The Adult Inpatient Prescription and Administration
record, dated 26” January 2016, notes in the section Allergies/intolerances a penicillin
and aspirin allergy which is then crossed out and the box signed as no known allergies.
Following discharge Peter Arthur Rowe developed a red scaly rash which worsened and
on the 1% February 2016 he was admitted to Stepping Hill Hospital with an initial
diagnosis of an infected (pustulated) psoriasis, which was changed the following day to
Toxic Epidermal Necrolysis, the likely pathogenesis of which was the administration of
Prophylactic co-amoxiclav on the 26” January 2016. Peter Arthur Rowe continued to
deteriorate and died on the 8” February 2016.
CONCLUSION: Misadventure
4 | CIRCUMSTANCES OF THE DEATH
The circumstances are as described above.
CORONER’S CONCERNS
1. That despite the GPs referral letter stating an allergy to penicillin, a penicillin
based prophylactic antibiotic was prescribed and administered.
2. The fact of the GPs referral etter stating an allergy to both penicillin and aspirin
appears to have been transferred on to the Adult inpatient Prescription and
Administration record and then deleted, albeit it is not clear by whom and when.
3. On the evidence heard at the Inquest Mr Rowe suffered from very poor memory
following his stroke in 1993. In the premises | am concerned that negative
answers to questions regarding any allergies stated to have been put to both Mr
Rowe al were accepted at face value when,
a) Mr Rowe suffered from significant memory loss and decreased cognitive
function, and
b) When EEE would not necessarily have known of her husband’s allergy
(and indeed did not).
The MATTER OF CONCERN is as follows,
in my opinion there is a risk that a similar situation may arise in the future and as such
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 my concerns.
ACTION SHOULD BE TAKEN
In my opinion action should be taken to develop a system, and to ensure its operation,
such that in circumstances where a patient is stated to have an allergy by a referring
doctor or other healthcare provider the fact of that statement should not be ignored
unless the patient him/herself is of full capacity and full cognitive function and is able to
deny any allergy so stated or the referring doctor is contacted for confirmation or further
information.
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report,
namely by 24" August 2016. |, 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.
| have also sent i fn
{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 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 Coroner.
29.06.2016 Mr Andrew Bridgman - Assistant Coroner
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