Zona Tebbs

On 12/h November 2018 commenced an investigation into the death of Zona Ethel Tebbs_ The investigation concluded at the end of inquest on 19 July 2019. The conclusion of the inquest was Narrative conclusion. "On 23 September 2018 Zona Ethel Tebbs sustained a garden injury for which she sought medical advice the following day: Failure to provide immunoglobulin on 24th September exposed her to a greater risk of developing tetanus and exposed to a greater risk of death: As it was Mrs Tebbs was admitted to hospital with tetanus on 2 October 2018 Her clinical course was complicated by acute on chronic myelopathy. She passed away in hospital on 5"h November 2018 from a combination of both these conditions

Mrs Tebbs was a fit and active 88 year old lady in good health: On the 23r September 2018 she Sustained a minor injury to her shin from a garden pick: The following she attended her general practitioner where the wound was dressed and she was given the tetanus vaccination On the October she was sufficiently unwell that an ambulance was called and she was taken to Doncaster Royal Infirmary: She was displaying early signs of tetanus but it was diagnosed at the time and she was discharged: She returned to hospital by ambulance on the 3r October where tetanus was raised but felt to be unlikely on the basis that this was a very rare condition and other differential diagnoses were explored. It is clear however that the clinical signs were consistent with tetanus One of the witnesses from the hospital told me that he was reassured by the fact that Mrs Tebbs had been given the tetanus vaccination by her GP On the 4th October her symptoms had worsened, tetanus was diagnosed and treatment commenced. Following the diagnosis there was consultation with the Infectious Diseases Unit at the Sheffield Trust and further research undertaken into the condition. As a result of these various enquiries it was established that Mrs Tebbs needed immunoglobulin which was administered to her the same During the course of the admission the spasms improved but she was suffering from muscle stamina and following an MRI a diagnosis of likely acute on chronic myelopathy with recovery considered extremely unlikely. Mrs Tebbs passed away on the 5th November 2018 Her cause of death was Ia. Generalised tetanus and acute on chronic myelopathy: Coroner'$ Court and Office, Doncaster Crown Court; College Road, Doncaster, DNI 3HS Tel 01302 737135 Fax 04302 736365 the thus her day 2nd not being day: heard evidence from a number of hospital doctors involved in treating Mrs Tebb' s condition and also fromi the general practitioner from the surgery concerned The evidence included details of the way in which critical information is communicated by Public Health England to Primary Care practitioners and a lack of clarity and direction for those involved in Primary Care Delivery as to changes. Concerns were raised regarding inadequate and ineffective communication of such matters; specifically with regard to the current case, was provided with evidence (supported by documentation detail below) that there had been significant changes to the definition of a tetanus prone wound and also changes to management of the same. Specifically, was referred to an email from Public Health England of July 2018 entitled "Vaccine Update" which highlights that month's additional features which included "tetanus specific immunoglobulin (TIG) supply shortage" There was nothing in that email to alert practitioners to the fact that the definition of tetanus prone wounds had changed nor the management had changed which must be critical features which ought to have been highlighted. was told by that in order to extract that information she had to click on the link in the email, then click on a further Iink which took her to the document and then she had to read through a significant amount of the document to find the part that dealt with matters have referred t0 above. She a further issue was that most (if not all) primary healthcare practitioners refer to the Green Book guidance which had not been updated in line with the July 2018 email: The final part of this evidence was that further guidance was circulated in November 2018 and that the Green Book was updated at this time As was told that Primary Care practitioners receive significant number of email communications at any given time, would seem essential to bullet the aspects of any such circulations thus pointing the practitioners in the right direction enabling them to research further the matters being raised. find it concerning that there was no bullet point of the change in definition of a tetanus prone wound or there had been a change to its management and it certainly caused difficulties for those treating Mrs Tebbs The need for tetanus vaccination was identified by the GP practice but given the circumstances set out above it was not appreciated that Mrs Tebbs also needed the immunoglobulin and this omission may well have played a part in her demise As have recorded in my conclusion the failure to give her immunoglobulin in line with the updated guidance exposed her to an increased risk of developing tetanus_ The final of evidence was that GPs within the Doncaster borough have expressed frustrations at poor communication from Public Health England and that the instance have described above in terms of that level of communication and extends more widely from this single issue _ consider that the failure to appropriately identify and effectively communicate changes which effect medical practices and patients will continue to put patients at risk thus considered a Prevention of Future Death Report was indicated

In my opinion action should be taken to prevent future deaths and believe you have the power to take such action.