Source · Prevention of Future Deaths
Edna Cleaton
Date: 17 Dec 2015
Coroner: Lousie Hunt
Area: Birmingham and Solihull
Responses identified: 0 / 1
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The practice lacked systems for regular medical reviews of patients on citalopram, resulting in a three-year delay in review and a missed opportunity to identify deterioration.
Date
17 Dec 2015
56-day deadline
11 Feb 2016 est.
Responses identified
0 of 1
Coroner's concerns
The practice lacked systems for regular medical reviews of patients on citalopram, resulting in a three-year delay in review and a missed opportunity to identify deterioration.
View full coroner's concerns
During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. (1) The evidence heard at the inquest was that patients on citalopram should be reviewed by a doctor every 3 – 6 months. This lady had not been reviewed for over 3 years. The practice need systems in place to ensure patients received appropriate medical reviews before repeat prescriptions are issued. Had regular reviews been undertaken it is possible that medical staff would have identified deterioration in the deceased and a care plan could have been instigated which may have avoided the pressure sores that developed.
Report sections
Investigation and inquest
On 21/10/2015 I commenced an investigation into the death of Edna May CLEATON DOB 30/08/1914, aged 101. The investigation concluded at the end of the inquest 16th December 2015. The conclusion of the inquest was that the deceased died from sepsis caused by sacral and leg pressure sores.
Circumstances of the death
The deceased died at her home address on 11/10/15. She had serious pressure sores which had become septic and caused her death. She had not been seen by a doctor for over 3 years despite being prescribed Citalopram for depression. The practice had been providing repeat prescriptions for this period.
Copies sent to
I am also under a duty to send the Chief Coroner a copy of your responseLouise Hunt Senior Coroner Birmingham and Solihull
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Report details
- Date of report
- 17 December 2015
- Coroner
- Lousie Hunt
- Coroner area
- Birmingham and Solihull
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: 11 Feb 2016 (estimated).
Sent to
- Jockey Road Medical Centre