Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0090, written 20 Mar 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 20 Mar 2022 |
|---|---|
| Reference | 2022-0090 |
| Deceased | Donald Compton |
| Coroner | Dr Sarah-Jane Richards |
| Coroner area | South Wales Central |
| Category | Wales prevention of future deaths reports (2019 onwards) · Hospital Death (Clinical Procedures and medical management) related deaths · Community health care · Other related deaths · Alcohol, drug and medication related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text extracted from the PDF text layer. 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:
1. Cwm Taf University Morgannwg Health Board;
1
1. CORONER
I am Dr. Sarah-Jane Richards, HM Assistant Coroner, for the Coroner area o f S outh Wales
Central.
2 CORONER’S LEGAL POWERS
I make this report under paragraph 7, Schedule 5, of the Coroners and Jus tice A ct 2009 and
regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.
3
INVESTIGATION and INQUEST
On 12 April 2021, I commenced an investigation into the death of Mr. Donald Vernon Compt on
The investigation concluded at Inquest on 24 February 2022.
The medical cause of death provided by consultant pathologist, Dr.
Hospital of Wales was:
, Universit y
1a Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis AND Covid-19
infection in a man with dilated cardiomyopathy and chronic renal failure
The Coroner’s narrative conclusion was:
Death of an 87 year old man with severe life threatening comorbidities who contracted Covid 19
and developed Stevens-Johnson Syndrome /Toxic Epidermal Necrolysis - the aetiology of
which was likely an adverse reaction to an antibiotic to which there was a known allergy.
4 CIRCUMSTANCES OF THE DEATH
These were recorded as:-
Donald Vernon Compton 87 years suffered a collapse at his home in Talb ot Green, Sout h
Wales and was admitted to the Royal Glamorgan Hospital (RGH) on 1st January 2021. He was
diagnosed as suffering tachycardia and severe left ventricular failure wit h parox ysmal at rial
f ibrillation, severe renal failure and previous stroke.
Once stabilised, he was transferred to a residential care home in To rb ay t o be c loser t o his
f amily. At some point he contracted Covid 19 and on 11 February 2021 was admitted to Torbay
and South Devon Hospital suf f ering f rom Stevens -Johnson Syndrome/Toxic Epidermal
Necrolysis - the likely aetiology being Co-trimoxazole, an antibiotic wit h t he cons tituent drug
trimethoprim to which Donald Compton had a known allergy. In spite of this allergy being
known, Mr. Compton was prescribed Co-trimoxazole as a part of his discharge medicat ions in
error and which was also erroneously approved by the overseeing pharmacist and ward nurses.
1
Mr. Compton lacked the reserve to combat the effects of Stevens-Johnson syndrome and Covid
19 and he passed away in the Torbay and South Devon Hospital on 14 February 2021.
Of f urther significant concern was i) a previous medication error after Mr. Compton’s admission
to the Royal Glamorgan Hospital in respect to amiodarone although without o bvious adver s e
ef f ect; and ii) Mr. Compton’s Torbay GP similarly prescribed Co-trimoxazole, even t hough t he
GP had been sent a discharge letter which clearly stated his patient’s allergy to t rimethoprim.
Fortunately, Co-trimoxazole was not provided to him.
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 further 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 f ollows:-
Prescribing and dispensing errors
1. At the time, the All Wales electronic prescribing tool (eDAL) permitted prescribers to
avoid reading the section concerning known allergies;
2. The commonly prescribed antibiotic Co-trimoxazole comprises two constituent drugs
trimethoprim and sulfamethoxazole. Allergies were not noted as Co-trimoxazole but to
the constituent drug, trimethoprim.
3. Prescribing hospital doctors; overseeing pharmacist; and ward nurses all failed to pick
up on this discharge prescribing and dispensing error suggesting drug safety on
discharge is an area for scrutiny and input to ensure a similar error is avoided a patient
saf ety is maximised.
4. That the Torbay GP also made an error in prescribing Co-trimoxazole to Mr. Compton
in the knowledge he was allergic to trimethoprim indicates the lack of specific
knowledge about this antibiotic and its constituent elements. It may also reflect a more
general lack of knowledge about constituent components of commonly prescribed
drugs.
5. A different prescribing error was made in respect of this same patient whilst under the
care of RGH. The down titration of Amiodarone was overlooked resulting in too high a
dose being administered over several days.
6 ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you and your
organisation have the power to take such action.
• Pharmaceutical product allergies to be noted on patient records not only by the
constituent drug name but also the name of the drug being prescribed in this cas e, t he
antibiotic Co-trimoxazole.
• Prescriptions to be noted on medical records/patient notes and discharge let t ers by
both their brand names and generic pharmaceutical names.
• Prescriptions to be noted on medical records/patient notes and discharge let t ers by
brand/generic name as well as constituent components e.g. Co-trimoxazole comprises
trimethoprim and sulfamethoxazole. Mr. Compton’s discharge letter states his allergy
was to trimethoprim.
• An inability to circumnavigate known allergy information b y Us ers of t he elect ronic
prescribing tool (eDAL)
2
7 YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report, namely
by 17 May 2022, allowing for statutory holidays. I may extend this period upon request.
Your response must contain details of action taken or proposed to b e t ak en, s ett ing o ut t he
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 Cwm Taf University Morgannwg Health Board, the Chief
Coroner and
(son of the deceased).
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 summ ary f orm. He
may send a copy of this report to any person who he believes may find it usef ul. 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.
9 Dated – 20 March 2022
SIGNED:
Dr. Sarah - Jane Richards, HM Assistant Coroner for South Wales Central
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