Coral O’Donnell

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS

THIS REPORT IS BEING SENT TO:

|) ii Clinical Director,

NHS Blackpool and NHS Fylde and Wyre Clinical Commissioning Groups,
Blackpool Stadium,

Seasiders Way,

Blackpool,

FY1 6JX

CORONER

lam Alan Anthony Wilson Senior Coroner for Blackpool & Fylde

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.
http://www. legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7
http://www.legislation.gov.uk/uksi/2013/1629/part/7/made

INVESTIGATION and INQUEST

The death of Coral Amy O’Donnell on 17** May 2019 was reported to me and | opened
an investigation, which concluded by way of an inquest held on 29" April 2021.

| determined that the medical cause of Elliot’s death was
la Panton valentin leukocidin staphylococcus aureus pneumonia
b Influenza A

ll Critical care acquired myopathy

The conclusion of the Coroner was that Coral died due to natural causes.

CIRCUMSTANCES OF THE DEATH
The circumstances were set out in box 3 of the Record of Inquest as follows:

Coral O’Donnell was regarded as previously healthy but was known to be susceptible to
developing skin infections. She had attended a General Practitioner in early November
2018 in relation to an abscess for which she was prescribed antibiotics. On 8th January
2019 Coral was assessed by a nurse having presented with cough and cold like symptoms
and after examination was felt to have developed a viral infection. After a deterioration
in her condition during 10th January 2019 Coral was admitted to hospital in Blackpool
that evening where investigations revealed she was neutropenic and concerns were
raised she has severe pneumonia. By the next morning she required intubation and
ventilation. Her history of skin infections, a known indicator of a very rare bacterial
infection, was not appreciated during the early part of her admission until around 21st
January 2019 when a concerning CT scan confirmed that this infection had been seriously
damaging Coral’s lungs and in the absence of necessary mediation. Over subsequent
weeks Coral’s condition fluctuated but she remained seriously unwell. Despite months

of intensive care, she could not be successfully weaned from ventilator support. Her
condition began to deteriorate further in early May 2019 before Coral died in the
company of her family on 17th May 2019.
In addition, | made the following findings:

e That Coral’s consultation with a GP, orm. in early November 2018 was
conducted in what appears to have been a proportionate manner;

e That although an expert witness told the court that the Panton Valentin
Leukocidin [PVL] strain of staphylococcus aureus [SA] often follows flu — like
symptoms and may affect otherwise healthy young people, | made no criticism
of the fact the GP did not know about PVL, particularly having considered the
rarity of the condition and the evidence of other experienced doctors seemingly
unfamiliar with PVL and by an independent GP who had never heard of it
before;

e That an independent microbiologist told the court that PVL—SA should be
suspected if there is evidence of recurrent abscesses. He added that SA is a
common bacterial infection, but the PVL is uncommon.

e That although no referral had been made to a dermatologist, no criticism was
made of this decision. The conduct of medical professionals who had assessed
Coral before her hospital admission had been considered by an independent GP;

e However, evidence was received that had such a dermatology referral been
made, this may have resulted in the earlier recognition of PVL.

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 could occur unless action is taken. In the
circumstances, it is my statutory duty to report to you.

The MATTERS OF CONCERN are as follows. —

e Although Staphylococcus aureus is a common bacterial infection, for the PVL
strain of that infection to lead to the lung damage suffered by Coral is very rare.
Nevertheless, one of the symptoms which may give medical professionals an
indication that a patient may be at risk of PVL — SA is a history of skin infections
and in otherwise healthy young people. There is clearly a lack of awareness of this
condition in both primary and secondary care and in the absence of efforts to
highlight this issue, young people such as Coral may continue to be placed at risk.

e The court was told that there is a Public Health England publication entitled
“Guidance on the diagnosis & management of PVL — associated Staphyloccocus
aureus infections”, but amongst medical professionals any awareness of this
guidance appears to be limited.

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 Tuesday, 6" July 2021. |, 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 and to the following interested
Persons:

e The Parents of Coral Amy O’Donnell
¢ Dr, Medical Director, Blackpool Teaching Hospitals NHS Foundation

Trust
Nurse Practitioner Jin
Dr GP

| 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, 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.

Date: 11/05/2021

Signature AL Asan~

Alan Anthony Wilson Senior Coroner Blackpool & Fylde

INHS

Blackpool Clinical Commissioning Group

| Fylde and Wyre Clinical Commissioning Group
The Stadium

22 June 2021 Seasiders Way
Blackpool

Mr A Wilson FY1 6X
HM Senior Coroner www. fyldecoastecgs.nhs.uk

Blackpool and Fylde Coroner’s Office
Municipal Building

Corporation Street

Blackpool!

FY1 1GB

Dear Mr Wilson

Thank you for asking the CCG to comment on the Regulation 28 report following the untimely death of
Coral O'Donnell on the 17" May 2019, as a consequence of an infection caused by Panton Valentine
Leukocidin Staphylococcus Aureus (PVL-SA).

Your comments express concerns about the lack of awareness of PVL-SA in both primary and secondary
care medical colleagues. You quite rightly point out that Public Health England have produced guidance on
the diagnosis and management of PVL-SA but, unfortunately, awareness of this guidance is limited amongst

medical professionals.

Given the implications this poses to the ongoing treatment of patients across the Fylde coast | have already
undertaken the following actions:

1. The matter has been discussed at our regular GP teleconference which takes place currently every
fortnight to which all GPs across the Fylde Coast are invited.

2. | have arranged for information to also be circulated via our regular CCG bulletin to general
practitioners, (sent weekly to all GPs). Our out of hours providers, FCMS are also copied into this
bulletin. For your records, a copy of the bulletin is enclosed with this letter. As you will note we
have directly referenced the information produced by Public Health England.

| have also noted that patient microbiology reports from our colleagues at Blackpool Teaching Hospitals
now contain a message to be aware of PVL-SA when a result has revealed a Staphylococcus organism.

| trust this information and actions meet with your approval. The CCG would welcome any other comments
you may have on the matter.

With kind regards.

Yours sincerely

Executive Clinical Director
Blackpool, Fylde and Wyre CCGs

Trust Headquarters 
Blackpool Victoria Hospital 
Whinney Heys Road 
Blackpool 
Lancashire 
FY3 8NR 

5 July 2021 

Mr Alan Anthony Wilson 
Senior Coroner Blackpool & Fylde 
PO Box 1066 
Corporation Street 
Blackpool 
FY1 1GB 

Your reference: Regulation 28 - Prevention of future deaths 

Dear Mr Wilson 

Re:  Coral Amy O’Donnell (deceased) – Inquest concluded 29 April 2021 

Further  to  your  Regulation  28  Report  to  Prevent  Future  Deaths,  dated  11  May  2021,  in 
relation to the death of Coral Amy O’Donnell, who sadly died in the company of her family on 
the intensive care unit of Blackpool Victoria Hospital on 17 May 2019. 

In my initial response letter, I explained that we would take actions to prevent a similar event 
from occurring. 

Below, I detail my responses to the matters of concern you  have raised with us and what 
action we have taken: 

1)  That when evidence of Staphylococcus Aureus was identified the clinical and 
microbiology  teams  did  not  consider  the  possibility  of  Panton  Valentine 
Leukocidin  (PVL)  Staphylococcus  Aureus,  despite  Coral’s  history  of  skin 
infections  and  the  severe  pneumonia  she  presented  with  on  admission  in  a 
previously young fit woman. 

Firstly,  I  must  apologise  that  we  failed  to  consider  or  identify  the  possibility  of  Panton 
Valentine Leukocidin (PVL) Staphylococcus Aureus for Coral.  The details and the outcome 
have  been  discussed  within  the  team  and  department  and  we  are  truly  sorry  for  what 
happened.  It  is  clear  from  the  Serious  Incident  review  that  there  was  a  general  lack  of 
awareness of this rare and serious strain of Staphylococcus Aureus within the Critical Care 
Consultant team. The report findings and the need to consider PVL has been shared with all 
the  clinical  staff  within  the  department  and  also  discussed  at  the  Morbidity  and  Mortality 

RESEARCH MATTERS AND SAVES LIVES - TODAY’S RESEARCH IS TOMORROW’S CARE 
Blackpool Teaching Hospitals is a Centre of Clinical and Research Excellence providing quality up to date care.  We are actively involved in undertaking research to 
improve treatment of our patients.  A member of the healthcare team may discuss current clinical trials with you. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 review meeting. The learning from this event will also be shared across the division and the 
wider organisation.  

Following  discussion  with  the  Microbiology  team,  we  have  ensured  that  the  Critical  Care 
Consultant team consider PVL Staphylococcus Aureus in all cases where Staphylococcus 
Aureus is isolated, particularly where the clinical picture supports such a diagnosis. As part 
of  our  learning,  we  have  had  a  very  low  index  for  initiating  triple  therapy  where  patients’ 
presentation  suggests  PVL  and  this  includes  commencing  Intravenous  IgG  in  several 
patients. We are now confident that a similar situation in the Intensive Care Unit would not 
be repeated and that any cases discussed with microbiology where PVL was clinically likely, 
patients would be commenced on PVL cover from the start; we are now treating non-PVL 
MRSA/MSSA patients, as well as PVL patients, with extended PVL regimes. 

2)  That there was a lack of awareness of PVL amongst senior clinicians, despite 
the  fact  that  a  senior  Microbiologist  from  the  hospital  Trust  confirmed  that 
national guidance covering the treatment of such condition was in use at the 
Trust at the time, but none of the critical care team who gave evidence at the 
inquest seem to have been aware of that document. Although the court was told 
this  has  now  been  rectified  there  is  a  concern  that  some  clinicians  are 
unfamiliar with hospital protocols which may be relevant to their work. 

We acknowledge that there was a lack of  awareness and knowledge with regards to PVL 
amongst the Critical Care Consultants, for which we apologise. As part of the discussions 
within  the  department,  the  Trust  PVL  policy  has  been  shared  with  all  the  Critical  Care 
Consultants.  The  importance  of  this  infection  has  been  discussed  at  the  departmental 
meetings. We can assure you that all the Critical Care Consultants are familiar with the Trust 
PVL document and we will continue to raise awareness amongst our colleagues and at local 
induction.  

3)  That  communication  between  the  critical  care  and  microbiology  teams  was 
problematic  and  neither  team  considered  PVL  until  there  was  established 
damage  to  her  lungs  identified  on  a  chest  x-ray.  Senior  clinicians  had  not 
mentioned a susceptibility to skin infections to the microbiologists which may 
have  resulted  in  Coral  receiving  the  correct  treatment  at  an  early  stage  of 
admission. The lack of communication between Microbiology and the clinical 
team appears to have in part been contributed to by a previous cessation of the 
thrice weekly joint microbiology and critical care ward rounds, which the court 
heard have not been re-instated. 

There  are  currently  no  joint  ward  rounds  between  the  Critical  Care  Team  and  the 
Microbiology  team,  but  there  is  better  day  to  day  communication  and  discussion  at  the 
Antimicrobial  Stewardship  Committee.  At  present,  the  day  to  day  system  is  via  telephone 
conversations  with  the  Microbiology  team,  as  and  when  required,  plus  the  Critical  Care 
Consultants  will  send  e-referrals  when  they  require  Microbiology  advice.  However,  we 
acknowledge that this falls short of what is ideal, and this needs to be improved. It has been 
highlighted that there is an objective to reinstate the three times a week joint ward round with 
the Consultant Microbiologist and Consultant Intensivist and the discussions to operationalise 
this are taking place. There are also imminent changes to the consultant staffing model that 
we believe will further improve matters. 

4)  That the number of microbiologists at the time of Coral’s admission was limited 
–  a  senior  Microbiologist  told  the  court  her  team  ought  to  comprise  six 
microbiologists,  but  were  limited  to  a  maximum  of  four  at  the  time  and  that 
remains the case. 

 
 
 
 
 
 
 
 
 
 
 The  Trust  is  undertaking  a  staffing  review,  which  takes  into  consideration  the  of  role  of 
infection  specialists  of  various  categories,  not  only  microbiology  trained  medics,  but  also 
Microbiologists,  Infectious  Diseases  Physicians,  PhD  grade  Antibiotic  Pharmacists  and 
Clinical Scientists with or without FRCPAth. 

5)  That there was a stark lack of awareness, noticeably amongst senior clinicians, 
about internal systems in place at the hospital Trust. The court heard about the 
Cyberlab system, and also a red flag system which the court was told a number 
of critical care clinicians had previously been unaware of. If clinicians have not 
received the necessary training in relation to such systems there is a risk they 
may not recognise potentially relevant information, placing patients at potential 
risk. 

We can only apologise that it has been highlighted that there was a lack of awareness with 
regards to the Cyberlab system and this is not acceptable.  All Critical Care Consultants have 
now  received  the  appropriate  training  relating  to  the  ‘red  flag’  system  and  how  to  access 
information. All new Consultants and junior doctors will receive Cyberlab training as part of 
their Trust induction. We will continue to raise awareness through education and training for 
all staff working on the unit to ensure that this does not recur.  

I hope that the above responses provide you with the assurance that we have taken your 
concerns extremely seriously. We have identified a number of learning opportunities, which 
we believe will prevent a similar situation from happening again.  

Yours sincerely, 

Executive Medical Director