Source · Prevention of Future Deaths

Joan Hanratty

Ref: 2018-0141 Date: 9 May 2018 Coroner: Chris Morris Area: Manchester (South) 0 responses identified · 1 indexed addressee View PDF

AI-generated concerns summaryThe practice of issuing antibiotics and steroids to COPD patients without a consultation lacks explicit advice for patients to seek medical help if their condition does not improve after starting the medication.

Date 9 May 2018

56-day deadline 4 Jul 2018 stated in the report

Responses identified 0 of 1

Community health care and emergency services related deaths

Coroner's concerns

AI summary

The practice of issuing antibiotics and steroids to COPD patients without a consultation lacks explicit advice for patients to seek medical help if their condition does not improve after starting the medication.

View full coroner's concerns

aged The day:

It was confirmed in the course of evidence given at the inquest that under certain circumstances, patients who have been diagnosed with, and are subject to regular review as a result of, Chronic Obstructive Pulmonary Disease are issued with prescriptions for antibiotics and steroids upon request and without requirement for a telephone or in-person consultation with a doctor. Whilst it is recognised that this practice accords with relevant clinical guidelines, it is a matter of concern that the system currently operated by the practice does not currently include explicit advice to patients that; in the event a significant improvement in condition is not experienced within a specified period of time of beginning antibiotic and steroid therapy, medical advice should be sought:

Report sections

Investigation and inquest

On 7th February 2018, | opened an inquest into the death of Joan Hanratty who was 75 years when she died at Tameside General Hospital, Ashton under-Lyne on 28'h January 2018_ The investigation concluded at the end of the inquest which heard on 30"h April 2018_ conclusion of the inquest was that Mrs Hanratty died a5 a consequence of septic shock due to pneumonia and Chronic Obstructive Pulmonary Disease against a background of multiple complex medical problems: At the end of the inquest;, recorded a conclusion of Natural Causes

Circumstances of the death

Mrs Hanratty had a complex medical history, which included heart failure, ischaemic heart disease , atrial fibrillation, hypertension and moderate to severe Chronic Obstructive Pulmonary Disease. On 23" January 2018,Mrs Hanratty contacted Denton Medical Practice and requested a prescription for antibiotics and steroids having developed a chest infection. As Mrs Hanratty was subject to regular review for her Chronic Obstructive Pulmonary Disease, a prescription for Amoxicillin and Prednisolone was issued automatically in accordance with relevant best-practice guidelines. On 28'h January 2018, Mrs Hanratty was brought into hospital by ambulance, having collapsed and suffered a cardiac arrest Despite attempts to resuscitate her, she sadly died in hospital later that

Action should be taken

In my opinion action should be taken to prevent future deaths and believe you and your organisation the power to take such action:

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Shared signals

Report details

Reference: 2018-0141
Date of report: 9 May 2018
Coroner: Chris Morris
Coroner area: Manchester (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: 4 Jul 2018 (stated in the report).

Sent to

Denton Medical Centre

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk.

Contains public sector information licensed under the Open Government Licence v3.0.