Source · Prevention of Future Deaths

Carol Buchanan

Ref: 2017-0294 Date: 12 Oct 2017 Coroner: Timothy Brennand Area: Manchester (West) Responses identified: 1 / 1 View PDF

Itraconazole was prescribed without consulting GP Summary Care, and the prescription was not timely recorded, leading to an unappreciated drug interaction with Simvastatin. Family concerns regarding the patient's deterioration were not adequately noted or acted upon, causing treatment delays.

Date 12 Oct 2017

56-day deadline 22 Jan 2018 est.

Responses identified 1 of 1

Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary

View full coroner's concerns

1. The prescription of Itraconazole was undertaken at the Royal Bolton Hospital’s Respiratory Outpatient Clinic without the consultation or cross referencing of the information contained in the “GP Summary Care” documentation;

2. In the absence of access to such documentation, clinicians are instructed to make use of information provided verbally by the patient/family or carer, which in the event of a patient presenting with complex co-morbidities requiring an extensive prescription regime can give rise to incomplete or inaccurate relevant prescription history;

3. The prescription of Itraconazole on the 27" April 2017 was not typed up into relevant records — either by way of the “GP clinic letter” or elsewhere in a timely or effective manner;

4. The very rare but serious drug interaction between Itraconazole and Simvastatin which contributed to the cause of death was not appreciated;

5. In the Divisional review undertaken by the Bolton NHS Foundation Trust it was noted that the correct diagnosis was assisted “with further information from the family” notwithstanding that in fact, between admission on the 18" May 2017 and the 21* May 2017 the family had made repeated representations and provided specific information in circumstances that demonstrate:-

a. The concerns and representations were not noted adequately; b. The importance of the history was not appreciated or acted upon; c. Missed opportunities arose between the 18” and 21% May 2017 to act on concerns relating to dehydration and urine output and a consequent delay in implementation of fluid balance monitoring;

. The delay in specific diagnosis of the underlying cause of the patients presenting symptoms;

Responses

1 respondent

Bolton NHS Trust NHS Trust

PDF

Noted

Response contains only illegible characters. (AI summary)

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Report sections

Investigation and inquest

On the 1* June 2017 I commenced an investigation into the death of Carol Buchanan, aged 65. The investigation concluded at the end of the inquest on the 6" October 2017.

The medical cause of death was:-

Ia Coronary Artery Thrombosis Ib Ischaemic Heart Disease

II Urosepsis and Rhabdomyolysis (clinical) My conclusion as to the death was “Misadventure”.

Circumstances of the death

The deceased had a history of previous stroke, morbid obesity, chronic obstructive pulmonary disease, cerebral vascular disease and asthma. As part of the ongoing treatment and care in the community the deceased had been prescribed Simvastatin therapy by her general practitioner. On the 27" April 2017, the deceased was prescribed a trial prescription of Itraconazole anti-fungal medication to treat diagnosed Aspergillus sensitization following analysis of results from recent blood tests at a respiratory outpatient service. The Simvastatin prescription appeared on a “GP Care Summary Record” but this information was not available at the outpatient clinic. Furthermore, there were no records at all of the Itraconazole prescription by reason of a delay in typing a clinic letter. On the 18° May 2017 the deceased was admitted as an inpatient at the Royal Bolton Hospital, Minerva Road, Farnworth, Bolton presenting with mptoms ultimately diagnosed as acute kidney injury with high potassium due to urine infection with dehydration. Her condition was managed conservatively and between 18 May 2017 and 21* May 2017 there were accepted missed opportunities to consider family concerns and information as to the deceased’s recent history of prescriptions and fluid imbalance as being causative or contributory to her deterioration. The combined prescription of Simvastatin and Itraconazole caused a rare but recognised complication in the form of a cross reaction leading to Rhabdomyolysis and muscle necrosis. The deterioration in her condition was recognised but its significance not appreciated until the 24" May 2017 when the consequences of the cross reaction of prescriptions was diagnosed upon the deceased being admitted to the intensive care unit. Despite active treatment and management thereafter, the condition of the deceased further deteriorated and on the 26" May 2017 she died.

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Report details

Reference: 2017-0294
Date of report: 12 October 2017
Coroner: Timothy Brennand
Coroner area: Manchester (West)

Responses identified

Responses identified 1 of 1

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 22 Jan 2018 (estimated).

Sent to

Royal Bolton Hospital

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk.

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