Source · Prevention of Future Deaths

Maureen Johnson

Ref: 2021-0298 Date: 7 Sep 2021 Coroner: Chris Morris Area: Manchester South Responses identified: 1 / 1 View PDF

A lack of authoritative national guidance for assessing gastroenteritis, dehydration, and the need for face-to-face reviews in patients over 70 poses a risk.

Date 7 Sep 2021

56-day deadline 2 Nov 2021 est.

Responses identified 1 of 1

Community health care and emergency services related deaths

Coroner's concerns

AI summary

A lack of authoritative national guidance for assessing gastroenteritis, dehydration, and the need for face-to-face reviews in patients over 70 poses a risk.

View full coroner's concerns

Given their physiological susceptibility to dehydration and its effects, it is a matter of concern that authoritative guidance does not currently exist as to the assessment of diarrhoea and vomiting suspected to be caused by gastroenteritis in the over 70s, as has previously been published in respect of children and infants younger than 5.

Such guidance might usefully provide a comprehensive overview of symptoms and signs of clinical dehydration in the over 70s, and give clinicians advice as to the circumstances in which a face-to-face assessment is recommended.

Responses

1 respondent

National Institute for Health and Care Excellence Other

2 Nov 2021 PDF

Noted

NICE states they have a Clinical Knowledge Summary on gastroenteritis, which they believe gives appropriate advice, and that no action is required of them. (AI summary)

View full response

Dear Mr Morris,

I write in response to your regulation 28 report of 7 September 2021 regarding the death of Maureen Johnson. I would like to express my sincere condolences to her family.

In your report you state that ‘authoritative guidance does not currently exist as to the assessment of diarrhoea and vomiting suspected to be caused by gastroenteritis in the over 70s, as has previously been published in respect of children and infants younger than 5.’

While it is correct that we have not published a clinical guideline on gastroenteritis in adults, or children over the age of 5, there is a Clinical Knowledge Summary on gastroenteritis which we believe gives appropriate advice on the assessment of people who are suspected to have gastroenteritis, including questions that healthcare professionals should ask, the need to examine the person, the risk of dehydration, and symptoms to be aware of.

While they do not constitute formal NICE guidance, we commission Clarity Informatics to develop the summaries, and make them available as a source of information for health professionals.

As such, we do not believe that any action is required of NICE.

Report sections

Investigation and inquest

On 26th March 2021, Christopher Murray, Assistant Coroner, opened an inquest into the death of Maureen Johnson who died on 13th March 2021 at Stepping Hill Hospital, Stockport, aged 85 years. The investigation concluded at the end of the inquest which I heard on 1st September 2021. A doctor treating Mrs Johnson confirmed that she had died as a result of:
1.a) Acute Renal Failure; due to
1.b) Dehydration;
1.c) Gastroenteritis II Hypertension. By way of conclusion, I recorded that Mrs Johnson died as a consequence of Natural Causes.

Circumstances of the death

Mrs Johnson was ordinarily a fit and active person who lived independently in her own home. Towards the end of February 2021, Mrs Johnson became unwell with diarrhoea, vomiting and abdominal pain. After around a week, Mrs Johnson’s symptoms had resolved, however returned again a number of days later. Mrs Johnson sought medical advice. In the two days prior to her death, two separate General Practitioners held telephone consultations with Mrs Johnson and formed the impression (albeit without examining her) that she had been suffering from a stomach bug which was resolving.

On 13th March 2021, Mrs Johnson’s son (who had been in regular contact with his mother throughout) spoke to her on the telephone and was concerned she sounded short of breath. On attending her home, Mr Johnson found his mother to be seriously ill.

An ambulance was called, and Mrs Johnson was taken to Stepping Hill Hospital where it was quickly recognised she had developed metabolic acidosis and was gravely ill. Despite attempts to provide emergency treatment, Mrs Johnson died later that afternoon.

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to the Inquest

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Report details

Reference: 2021-0298
Date of report: 7 September 2021
Coroner: Chris Morris
Coroner area: Manchester South

Responses identified

Responses identified 1 of 1

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 2 Nov 2021 (estimated).

Sent to

National Institute for Health and Care Excellence

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.