Source · Prevention of Future Deaths
Lindsey Tyrrell
Ref: 2018-0208
Date: 29 Jun 2018
Coroner: Anthony Mazzag
Area: Manchester (City)
0 responses identified · 2 indexed addressees
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AI-generated concerns summaryThe coroner noted that prior to the death, The Christie Hospital did not routinely test allogeneic stem cell transplant patients with infection signs for toxoplasmosis. The report suggests this learning should be shared nationwide with other specialist blood cancer care units.
Date
29 Jun 2018
56-day deadline
9 Oct 2018 est.
estimated from the Judiciary.uk publication date
Responses identified
0 of 2
Coroner's concerns
The coroner noted that prior to the death, The Christie Hospital did not routinely test allogeneic stem cell transplant patients with infection signs for toxoplasmosis. The report suggests this learning should be shared nationwide with other specialist blood cancer care units.
View full coroner's concerns
heard evidence at the Inquest that toxoplasmosis IS carried by about 30% of the population, however prior to Mrs Tyrell's death testing for this Infection was not routinely carried out at the Christie Hospital on patients who had received an allogeneic stem cell transplant and who had subsequently presented with signs of Infection heard evidence that;, following Mrs Tyrell's death, testing for toxoplasmosis IS now undertaken at the Christie Hospital when stem cell transplant patients present In similar circumstances However; there was no evidence before me as to the practice of other specialist blood cancer care units or hospitals In similar circumstances It seems appropriate that the learning from this incident at a local level should be shared on a nationwide basis
Report sections
Circumstances of the death
In November 2014, Mrs Tyrell was diagnosed With B-cell Acute Lymphoblastic Leukaemia (B-ALL') She was commenced on intensive chemotherapy which she tolerated well She achieved complete remission of her disease and was moved to maintenance therapy In September 2015 Unfortunately, In December 2016, It was noted that her bloods were deteriorating and marrow Investigations revealed relapse of her B-ALL At that stage, the only prospect for long term survival was an allogenelc stem cell transplant Accordingly, on March 2017, Mrs Tyrell underwent an unrelated donor stem cell transplant She received appropriate Immunosuppressive treatment and was therefore at high risk of developing_an Infection over the next 12 months 24th
At the beginning of June 2017 , Mrs Tyrell presented at the Christie Hospital with headaches, fever and an intermittent rash She had clearly developed an infection by that point Investigations were carried out to Identify the nature of the Infection However _ no evidence of Infection was found on routine blood testing She was also routinely scanned for evidence of infection In her brain but nothing abnormal was noted Mrs Tyrell continued to deteriorate On 21st June a lumbar puncture test was performed but no infection was found In the cerebrospinal fluid ('CSF' Over the course of 27th June to 29th June, there was significant deterioration In Mrs Tyrell's condition and by 30th June, the prognosis was terminal She passed away on 3rd July 2017 Following her death, the Christie Hospital reanalysed the bloods taken during the course of Mrs Tyrell's last admission to hospital It was found that her blood samples from 5ih June 2017 onwards tested positive for toxoplasma The CFS from 21st June was also retested and found to be positive for toxoplasma
At the beginning of June 2017 , Mrs Tyrell presented at the Christie Hospital with headaches, fever and an intermittent rash She had clearly developed an infection by that point Investigations were carried out to Identify the nature of the Infection However _ no evidence of Infection was found on routine blood testing She was also routinely scanned for evidence of infection In her brain but nothing abnormal was noted Mrs Tyrell continued to deteriorate On 21st June a lumbar puncture test was performed but no infection was found In the cerebrospinal fluid ('CSF' Over the course of 27th June to 29th June, there was significant deterioration In Mrs Tyrell's condition and by 30th June, the prognosis was terminal She passed away on 3rd July 2017 Following her death, the Christie Hospital reanalysed the bloods taken during the course of Mrs Tyrell's last admission to hospital It was found that her blood samples from 5ih June 2017 onwards tested positive for toxoplasma The CFS from 21st June was also retested and found to be positive for toxoplasma
Action should be taken
In my opinion action should be taken to prevent future deaths and belleve you and your organisation have the power to take such action
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Report details
- Reference
- 2018-0208
- Date of report
- 29 June 2018
- Coroner
- Anthony Mazzag
- 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: 9 Oct 2018 (estimated from the Judiciary.uk publication date).
Sent to
- Department of Health and Social Care
- NHS England