Source · Prevention of Future Deaths
Patricia McAdam
Ref: 2020-0093
Date: 15 Apr 2020
Coroner: S Ormond-Walshe
Area: London (South)
Responses identified: 0 / 1
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The GP practice lacked a system to regularly assess vulnerable patients who refused care, despite continuing repeat prescriptions, posing a risk that deteriorating conditions would go unaddressed.
Date
15 Apr 2020
56-day deadline
9 Jul 2020 est.
Responses identified
0 of 1
Coroner's concerns
The GP practice lacked a system to regularly assess vulnerable patients who refused care, despite continuing repeat prescriptions, posing a risk that deteriorating conditions would go unaddressed.
View full coroner's concerns
During course of the inquest, the evidence revealed matters giving rise to concern: In opinion; there is a risk that future deaths could occur unless action is taken. : Atrs MAcAd2m "2s known to be wheelchair bound due t0 arthritis and was a smoker with Perplieral vasculai disease_ She was cared for at home by her daughter: She died at Croydoii Uriversity {iospital oii 11 Jirie 2C;8 froivi coiplicatioiis associated with infected leg ulcers She had not heen seen by a GP since 13" luily 2015 Althouigh there WAS 3 large cicicnt of thc paticn: Kerself Zeclizirg cortact &..2 care #ron Lealtkcare Zrovilers,Ler Iepeat prercripticcz (cf Cramcrpt; cc-ccJarcl, AAmitrict;lc znd the my
Furosemide) continued despite there being no obvious regular attempt; or any; to assess and check up on her: Caring for patients refusing patient care is obviously challenging: However, am concerned that there is a system in place in the future to ensure that these patients are regularly assessed, even if that assessment bears no fruit due t0 a competent patient declining help. am reassured that the GP practice has put into place a svstem now whereby these patients do not get forgotten but this report asks for confirmation of such a system:
Furosemide) continued despite there being no obvious regular attempt; or any; to assess and check up on her: Caring for patients refusing patient care is obviously challenging: However, am concerned that there is a system in place in the future to ensure that these patients are regularly assessed, even if that assessment bears no fruit due t0 a competent patient declining help. am reassured that the GP practice has put into place a svstem now whereby these patients do not get forgotten but this report asks for confirmation of such a system:
Report sections
Investigation and inquest
On Znd June 2018 commenced an investigation into the death of Mrs Patricia Mcadam: The investigation concluded at the end of the inquest on 13" March 2020. The medical cause of death was: Ia. Multi-Organ failure 1b. Septic Shock Ic. Infected leg ulcers (with osteomyelitis) and peripheral vascular disease
2. iutiobiiiiy due i0 rfleurraidid ariiiriiis arid iOw body Ilass irdex (cacilexis The conclusion of the inquest was that Patricia Mcadam died suffering sepsis caused by pelipiierai vascuial uisease alid ilbiiiiy
2. iutiobiiiiy due i0 rfleurraidid ariiiriiis arid iOw body Ilass irdex (cacilexis The conclusion of the inquest was that Patricia Mcadam died suffering sepsis caused by pelipiierai vascuial uisease alid ilbiiiiy
Circumstances of the death
The deceased was known to be wheelchair bound due to her arthritis and was smoker with peripheral vascular disease_ She was cared tor at home by her daughter On 31st May 2018 she was admitted to Croydon University Hospital in a state of extremis. Her pressure sores and leg ulcers were Grade 4-She died of sepsis eleven days later on I1th June 2018 Post mortem examinations have identified old rib fractures, which could have happened with trivial torce_ There is some evidence that the deceased retused care in the years preceding her state of extremis in May 2018. She was a frail, elderly lady who had not seen her GP for a long time and the District Nurses since 2015_ There is a natural causes element to her death, particularly in relation to her arthritis and peripheral vascuiar diseasa
Action should be taken
In my opinion action should be taken to prevent future deaths and believe you and your organisation have the power to take such aciion
Copies sent to
Walshe HM Senior Coroner duty
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Report details
- Reference
- 2020-0093
- Date of report
- 15 April 2020
- Coroner
- S Ormond-Walshe
- Coroner area
- London (South)
Responses identified
Responses identified
0 of 1
1 response not yet linked
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 9 Jul 2020 (estimated).
Sent to
- GP Surgery Parkway Health Centre