Source · Prevention of Future Deaths
Graham Earl
Ref: 2019-0323
Date: 30 Sep 2019
Coroner: Alison Mutch
Area: Manchester (South)
Responses identified: 0 / 3
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GPs lacked understanding of medication links to pulmonary fibrosis, failed to seek specialist guidance before amending prescriptions, and were unaware of side effect escalation procedures.
Date
30 Sep 2019
56-day deadline
3 Jan 2020 est.
Responses identified
0 of 3
Coroner's concerns
GPs lacked understanding of medication links to pulmonary fibrosis, failed to seek specialist guidance before amending prescriptions, and were unaware of side effect escalation procedures.
View full coroner's concerns
1 _ The GPs involved did not understand or recognise the known link between the therapy and Pulmonary Fibrosis and did not seek guidance from the prescribing secondary care physician at an early stage. The evidence was that the advice would have been to prescribing immediately; A GP amended the prescription subsequently without reference to the secondary care doctor despite the fact that this is not a medication started in primary care;
3. The indication was that GPs involved were not aware of what should do if there were side effects from the medication in terms of escalation; The drug is currently green on the CCG classification. In other CCG areas it is amber given the known side effects.
3. The indication was that GPs involved were not aware of what should do if there were side effects from the medication in terms of escalation; The drug is currently green on the CCG classification. In other CCG areas it is amber given the known side effects.
Report sections
Investigation and inquest
On 20th February 2019 / commenced an investigation into the death of Graham Earl. The investigation concluded on the 14h August 2019 and the conclusion was one of Narrative: Died from influenza exacerbated by the complications of prescribed medication, namely Amiodarone. The medical cause of death was 1a) Influenza Pneumonia on a background of Pulmonary Fibrosis caused by Amiodarone therapy; WV) Diabetes Mellitus (Type 2), Ischaemic Heart Disease, Atrial Fibrillation
Circumstances of the death
Graham Earl had a history of Atrial Fibrillation: A Cardioversion on 2nd 2018 successfully restored his heart rhythm: Amiodarone was prescribed to maintain his rhythm. On 2nd January 2019 he was diagnosed via a chest x-ray with Pulmonary Fibrosis, a known complication of Amiodarone therapy: He was not referred back to the cardiologist: Had he been referred back, the Amiodarone would have been stopped. He continued to deteriorate: On 14t February 2019 he was acutely unwell and was admitted to Stepping Hill Hospital. He was diagnosed with influenza. His Pulmonary Fibrosis exacerbated the impact of the influenza. He deteriorated and died at Stepping Hill Hospital on 16th February 2019.
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: May stop they
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Report details
- Reference
- 2019-0323
- Date of report
- 30 September 2019
- Coroner
- Alison Mutch
- Coroner area
- Manchester (South)
Responses identified
Responses identified
0 of 3
3 responses not yet linked
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 3 Jan 2020 (estimated).
Sent to
- Greater Manchester Health and Social Care Partnership
- Park View Group Practice
- Stockport Clinical Commissioning Group