Source · Prevention of Future Deaths
Margaret Wilson
Ref: 2019-0163
Date: 11 Mar 2019
Coroner: Jean Harkin
Area: Manchester (City)
0 responses identified · 2 indexed addressees
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AI-generated concerns summaryThe coroner identified that a blood test, compliant with national guidelines, was not performed, which would have confirmed Endocarditis. The absence of this test and the prescribed antibiotics masked the disease, leading to a delayed diagnosis and treatment that likely altered the outcome.
Date
11 Mar 2019
56-day deadline
23 Sep 2019 est.
estimated from the Judiciary.uk publication date
Responses identified
0 of 2
Coroner's concerns
The coroner identified that a blood test, compliant with national guidelines, was not performed, which would have confirmed Endocarditis. The absence of this test and the prescribed antibiotics masked the disease, leading to a delayed diagnosis and treatment that likely altered the outcome.
View full coroner's concerns
1. A blood test should have been done, in compliance with national guidelines, which would have confirmed Endocarditis. The absence of such test and the prescribing of antibiotics masked the disease.
2. Earlier diagnosis and treatment would more likely than not have resulted in a different outcome.
In addition it was later recognised that the finger symptoms were most likely due to Endocarditis.
2. Earlier diagnosis and treatment would more likely than not have resulted in a different outcome.
In addition it was later recognised that the finger symptoms were most likely due to Endocarditis.
Report sections
Investigation and inquest
I concluded the inquest into the death of Margaret Bernadette WILSON on 17 July 2018 and recorded that he/she died from:
1a Cardiac failure and arrest
1b Acute myocardial infarction and acute aortic valve endocarditis (with surgical intervention on July 18th 2017).
1a Cardiac failure and arrest
1b Acute myocardial infarction and acute aortic valve endocarditis (with surgical intervention on July 18th 2017).
Circumstances of the death
Mrs Wilson was admitted to Trafford General Hospital Urgent Care centre on the 18th of June 2017 complaining of swelling and pain in her right arm and shoulder, she also had bruising and swelling of her index and middle finger for four days.
She was provisionally diagnosed with cellulitis and antibiotics were started. Of note, no blood tests were performed prior to commencing antibiotics.
On the 2nd of July 2017 the deceased complained of central crushing chest pain and was transferred to Manchester Royal infirmary. Endocarditis was then diagnosed however, despite treatment, the deceased failed to respond and died on 20th July 2017. I attach a copy of the record of inquest confirming the cause of death.
Evidence heard at the Inquest confirmed that a blood test ought to have been performed prior to the prescribing of antibiotics.
She was provisionally diagnosed with cellulitis and antibiotics were started. Of note, no blood tests were performed prior to commencing antibiotics.
On the 2nd of July 2017 the deceased complained of central crushing chest pain and was transferred to Manchester Royal infirmary. Endocarditis was then diagnosed however, despite treatment, the deceased failed to respond and died on 20th July 2017. I attach a copy of the record of inquest confirming the cause of death.
Evidence heard at the Inquest confirmed that a blood test ought to have been performed prior to the prescribing of antibiotics.
Similar PFD reports
Report details
- Reference
- 2019-0163
- Date of report
- 11 March 2019
- Coroner
- Jean Harkin
- Coroner area
- Manchester (City)
Responses identified
Responses identified
0 of 2
2 responses not yet linked
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 23 Sep 2019 (estimated from the Judiciary.uk publication date).
Sent to
- MET
- MFT