Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0443, written 29 Aug 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 29 Aug 2025 |
|---|---|
| Reference | 2025-0443 |
| Deceased | Audrey Newman |
| Coroner | Andrew Bridgman |
| Coroner area | Manchester South |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Stockport NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: The CEO, Stockport NHS Foundation Trust 1 CORONER lam Andrew Bridgman, Assistant Coroner, for the coroner area of Manchester South 2 | CORONER’S LEGAL POWERS I 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 12.03.25 an inquest was opened into the death of Audrey Newman who died at Stepping Hill Hospital on 24 November 2024. The inquest concluded on 22.08.25. The investigation concluded on 03.02.23. 1a) Renal failure 1b) Acyclovir treatment 1c) Encephalopathy of unknown cause The conclusion was one of Died from recognised risks of antiviral therapy for a suspected life-threatening condition. 4 | CIRCUMSTANCES OF THE DEATH Audrey Newman was admitted on the evening of 10 November 2024 following a seizure at home. The working diagnosis was a suspected encephalitis and in accordance with guidelines treatment with antibiotics and antivirals (acyclovir) was commenced that evening. A lumbar puncture was planned for 11 November 2024 as part of the diagnostic pathway. It was not carried out, according to the Trust’s Lessons Learned Overview, because there was a lack of competent ward doctors to carry out such a procedure, especially for a patient as AN who was agitated and confused. A lumbar puncture was eventually carried out on 18 November 2024 by the anaesthetic team - it was negative. The Trust also acknowledge in its LLO that delay occurred because no one consultant took ownership of the need and arrangements for the lumbar puncture. On the pathological evidence, and that the lumbar puncture on 18 November was negative and that the Trust’s witness talking to the LLO was not able to provide a rationale as to why the Trust felt that had a lumbar puncture been carried out on 11 November it would have been positive — the inquest determined that had a lumbar puncture been carried out on 11 November 2024 it would likely have been reported, within 24hrs, as negative and the antiviral and antibiotic treatment stopped sometime on 12 November 2024. Antiviral (and antibiotic) treatment continued on 12, 13, 14, 15 and 16 November 2024, albeit on a decreasing dosage from 13 November as there were concerns about diminishing renal function; a recognised complication of acyclovir. By 17 November 2024 AN had developed severe renal failure which did not respond to treatment. No clinical or pathological cause was found for the presenting encephalopathy, namely the seizure and low conscious level; it is unlikely to have been infective encephalitis. It was not possible to determine whether or not, had the antiviral and antibiotic treatment been stopped on 12 November 2024, AN would not have progressed to severe renal failure. 5 | CORONER’S CONCERNS The evidence of the Trust was that CSF analysis was CRUCIAL for diagnosing meningitis or encephalitis when infection is suspected. Further, acyclovir is well recognised as a drug giving rise to renal injury. In its LLO the Trust stated that, in recognition of the lack of training to enable ward doctors to undertake lumbar puncture a series of training sessions were held and are to continue. Within the LLO it is stated, There is learning in relation to escalation by doctors when a lumbar puncture is needed and hasn't been done either due to difficulty (eg agitation) or unavailability of competency trained doctors. This has been discussed and case shared at the general medicine teaching sessions in April 2025. The witness speaking to the LLO said that requests for escalation are still informal and based on goodwill. There is no formal process for requesting assistance. The issue of concern is that in the absence of a formal pathway or referral process to the anaesthetic team for those cases which fall into the above category there is a significant risk of future delays in carry out crucial diagnostic tests, and a risk of death. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent the risk of 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 24th October 2025. | 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 namely Mrs Newman’s family, who may find it useful or of interest. lam 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. Andrew Bridgman HM Assistant Coroner 29/08/2025
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.
PRIVATE AND CONFIDENTIAL Mr A. Bridgman HM Assistant Coroner Manchester South Coronial Area Mount Tabor Street Stockport SK1 3AG Ref: Ms Audrey Newman DOB: 08/06/1950 DOD: 24/11/2024 Dear Mr Bridgman, Oak House Stepping Hill Hospital Poplar Grove Stockport Cheshire SK2 7JE 06 November 2025 I am writing to you further to the conclusion of the inquest into the death of Ms Audrey Newman on 22 August 2025, and in response to your request for assurance regarding the circumstances surrounding her care, specifically in the absence of a formal pathway or referral process to the anaesthetic team regarding Lumbar puncture procedure (LP) We would like to begin by expressing our sincere condolences to Ms Newman’s family. We recognise the distress caused by the events leading to her death and are committed to learning from this case to improve patient safety and care. Within adult medicine the number of lumbar punctures performed per week average between 10-15. The vast majority of these are done in a very timely manner i.e. within 12-24 hours, and within either the acute medical unit (AMU) or the medical same day emergency care unit (SDEC). Most lumbar punctures are done to exclude either a small brain bleed or meningitis. In rare cases they are done to exclude encephalitis or other more rare nervous system conditions. Very few LPs are done on the specialty medical wards as most would have been done within the first 24-72 hours of the admission on AMU or SDEC. The vast majority of LPs are done on AMU or SDEC and are successful in obtaining samples. On a few occasions the procedure is challenging. This is usually due either to the patient’s body habitus (obese patients or those with spinal bone deformities) or in more rare cases because the patient is non-compliant or agitated. There is a process in place by which teams contact the anaesthetic team, in cases where the initial LP attempt failed. This involves contacting the anaesthetic senior doctor on call and once they agree to list the procedure by the anaesthetic team the patient is either transferred to theatre for the procedure to be performed or the anaesthetic team attend the ward to perform the procedure. The timeliness can vary and is dependent on other life-threatening emergencies that may need a much more urgent slot in theatre. Unfortunately, in Mrs Newman’s case despite the anaesthetic team being informed of the need for assistance in performing the procedure, there were delays, and as a result, we have enacted a program of work to tighten the process and prevent this from happening again. The details of this are outlined below: 1) In conjunction with the postgraduate department and some of the senior doctors within acute medicine, we have enacted a training program for all registrars working on the medical specialty wards to be signed off to perform lumbar punctures. The program involves signed off simulation sessions within the postgraduate department, then a supervised signed off procedure on a patient. Most registrars who have joined from overseas were competent in performing the procedure but required refresher training given the anxiety of joining a new healthcare system. This program is ongoing and I can report that all registrars have done the simulation sessions and the signing off for the live procedures is ongoing. 2) A meeting was arranged between senior members of the anaesthetic team and (Divisional Medical Director for Medicine and Urgent Care) to formalise the process of escalation of difficult LPs to the anaesthetic team: • Training is being rolled out to all medical staff within the division of medicine to use the IT booking system for theatres (Theatreman) – this will allow any agreed procedure escalated to the anaesthetic team to be logged, giving visibility that a procedure is pending, and providing an audit trail. The lack of training in using this system was an issue as procedures would be agreed to be done by the anaesthetic team, but then there would be a delay in logging the procedure on Theatreman. It is important to note that this system would be very rarely used by staff in the medical division as they do not work in theatres which is why training was not part of the induction. • The process of escalation to anaesthetics is being formulated into a flow chart that will be cascaded to all clinicians in the division of medicine and urgent care. • Patients awaiting a lumbar puncture to exclude meningitis, encephalitis, or subarachnoid haemorrhage will not be transferred off the acute medical unit until the LP is performed successfully. If there is a need to escalate after failed attempts then this needs to be agreed and logged onto Theatreman before the patient is transferred to another medical ward. • Patients awaiting a lumbar puncture will not be transferred off the unit on a Friday, Saturday or Sunday to avoid weekend related delays. The elements above will prevent the delays that occurred in Mrs Newman’s case although one must note that to totally exclude encephalitis one would need a viral PCR which can take a number of days for the results to come back. We hope the information provided above offers assurance that Stockport NHS Foundation Trust has taken the findings of the inquest into Ms Audrey Newman’s care extremely seriously. We remain dedicated to continuous improvement in patient safety and care quality. Should you require any further information, please do not hesitate to contact me. Yours faithfully Chief Executive
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