Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0082, written 22 Feb 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 22 Feb 2019 |
|---|---|
| Reference | 2019-0082 |
| Deceased | Gabriele Kreichgauer |
| Coroner | Philip Barlow |
| Coroner area | London Inner (South) |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Barts Health NHS 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.
ANNEX A REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 41. Barts Health NHS Trust 1 | CORONER lam Philip Barlow, assistant coroner, for the coroner area of Inner South London 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 1 February 2018 | commenced an investigation into the death of Gabriele Kreichgauer, age 61. The investigation concluded at the end of the inquest on 15 February 2019. The conclusion of the inquest was that Ms Kreichgauer died of sepsis following an infected cat bite of her hand. 4 | CIRCUMSTANCES OF THE DEATH Ms Kreichgauer attended Newham General Hospital ASE on 21 January 2018 with an infected cat bite in her hand. It was intended that she should receive antibiotics but these were not given to her and she was discharged from the department. She went on to develop sepsis and died at Queen Elizabeth Hospital on 23 January 2018. 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. — (1) Ms Kreichgauer left the department without being given antibiotics. The reason for this appears to have been that no-one did a final check on what treatment was considered and whether this had been given to her. (2) The junior doctor who saw Ms Kreichgauer used an internet resource called “Uptodate”. The evidence was that the Trust supplies the subscription for this. He searched under the phrase “cat bite” and was directed to a diagnosis of cat scratch fever. On this basis he planned to prescribe azithromycin. in fact, the correct diagnosis was that Ms Kreichgauer had an infected cat bite; the infective organism for this is different to the organism causing cat scratch fever; and the appropriate treatment is different. Even if she had been given antibiotics it is therefore likely that these would not have been effective. At the inquest the clinicians accepted that it would be helpful for there to be a warning on Uptodate pointing out the need to consider the possibility of infected cat bite (and the important difference between this and cat scratch fever) when searching under either term (‘cat bite” or “cat scratch”. It was accepted that the Trust should be in a position to communicate with Uptodate to point out this concern. (3) There does not appear to be a feedback mechanism within Uptodate to allow clinicians to notify it of any concerns. Again, as a subscriber to Uptodate, this is a matter that the Trust is likely to be in a position to take up with them. ACTION SHOULD BE TAKEN in my opinion action should be taken to prevent future deaths and | believe you and/or your organisation 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 23 April 2019. |, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetabie for action. Otherwise you must explain why no action is proposed. COPIES and PUBLICATION | have seni a copy of my report to the Chief Coroner and to the family as an Interested Person. | 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. 22 February 2019 Philip Barlow
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