Homerton University Hospital NHS Trust
NHS / Health Body
Action Taken
The hospital disseminated information about Staphylococcal Toxic Shock Syndrome to clinicians, including an evidence and literature search. The case will be discussed at a Hospital Grand Round, and the Trust is focusing on early recognition and treatment of sepsis. (AI summary)
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Dear Coroner Hassell,
Re: Prevention of Future Deaths notice in relation to Staphylococcal Toxic Shock Syndrome
Thank you for the email sent on 21st March, which contained a Prevention of Future Deaths notice in relation to the care of Mrs Rubana Pathan. As you know, Mrs Pathan sadly died on 21st November 2015 from Staphylococcus aureus Toxic Shock Syndrome following breast implant surgery. In the PFD, you requested that we disseminate information about this particular and rare manifestation among our clinicians who are responsible for caring for patients who are at risk of developing sepsis. I am writing to confirm the actions undertaken in response by Homerton University Hospital.
1. I requested that , the microbiologist who gave evidence at the inquest, perform an evidence and literature search on surgical site Staphylococcal Toxic Shock Syndrome, with particular reference to suppression of pus formation resulting in benign-looking wounds.
2. I have highlighted the need to have a high index of suspicion for sepsis associated with Staphylococcal Toxic Shock Syndrome, and shared detailed literature search, with all doctors in the Trust by email.
3. The case will be discussed in detail at a Hospital Grand Round, in order to ensure that the organisation learns as much as possible from this sad occurrence. The Grand Round was scheduled to take place on 26th April, but unfortunately had to be postponed due to the junior doctors’ industrial action which took place that day, so will take place on 28th June.
4. The Trust has directed particular focus on encouraging early recognition and treatment of patients with sepsis, as part of its Improving Quality programme. In Quarter 4 of 2015-16 we were extremely pleased that all patients admitted to Homerton with severe sepsis received antibiotics within one hour. In 2016/17, we are broadening the focus of this programme, seeking to improve the recognition, escalation and treatment of patients on our in-patient wards with potential sepsis.
Coroner Mary Hassell Senior Coroner Inner North London St Pancras Coroner’s Court Camley Street London, N1C 4PP
By email to Coroner’s office:
Incorporating hospital and community health services, teaching and research
- 2 - I do hope that this provides assurance that we have taken appropriate action in response to the PFD notice. Please do not hesitate to contact me if you require any further information.
Re: Prevention of Future Deaths notice in relation to Staphylococcal Toxic Shock Syndrome
Thank you for the email sent on 21st March, which contained a Prevention of Future Deaths notice in relation to the care of Mrs Rubana Pathan. As you know, Mrs Pathan sadly died on 21st November 2015 from Staphylococcus aureus Toxic Shock Syndrome following breast implant surgery. In the PFD, you requested that we disseminate information about this particular and rare manifestation among our clinicians who are responsible for caring for patients who are at risk of developing sepsis. I am writing to confirm the actions undertaken in response by Homerton University Hospital.
1. I requested that , the microbiologist who gave evidence at the inquest, perform an evidence and literature search on surgical site Staphylococcal Toxic Shock Syndrome, with particular reference to suppression of pus formation resulting in benign-looking wounds.
2. I have highlighted the need to have a high index of suspicion for sepsis associated with Staphylococcal Toxic Shock Syndrome, and shared detailed literature search, with all doctors in the Trust by email.
3. The case will be discussed in detail at a Hospital Grand Round, in order to ensure that the organisation learns as much as possible from this sad occurrence. The Grand Round was scheduled to take place on 26th April, but unfortunately had to be postponed due to the junior doctors’ industrial action which took place that day, so will take place on 28th June.
4. The Trust has directed particular focus on encouraging early recognition and treatment of patients with sepsis, as part of its Improving Quality programme. In Quarter 4 of 2015-16 we were extremely pleased that all patients admitted to Homerton with severe sepsis received antibiotics within one hour. In 2016/17, we are broadening the focus of this programme, seeking to improve the recognition, escalation and treatment of patients on our in-patient wards with potential sepsis.
Coroner Mary Hassell Senior Coroner Inner North London St Pancras Coroner’s Court Camley Street London, N1C 4PP
By email to Coroner’s office:
Incorporating hospital and community health services, teaching and research
- 2 - I do hope that this provides assurance that we have taken appropriate action in response to the PFD notice. Please do not hesitate to contact me if you require any further information.