Stephen Widman

1. There should be an accelerated pathway for individuals suffering neuropenic sepsis so they are dealt with promptly. On the evidence at this Inquest it was inappropriate for the deceased to sit for several hours in the Accident and Emergency Department.

2. The deceased was catheterised too frequently without the management of a urologist.

Evidence was received that there is an advantage in treating patients promptly on arrival at Accident and Emergency and that treatment could be expedited if patients were issued with a card noting their vulnerability and bringing with them a contact telephone number.

Action should be taken

Evidence was received that a Consultant could issue a vulnerable patient (particularly patients who are vulnerable because of cancer treatment) with a card to present at an Accident and Emergency Department which would read to the effect “I am vulnerable because .... please contact x on my behalf”. The evidence received was that this would be particularly helpful during weekends. The issue of such cards should be at the discretion of the Consultant having care of the patient.

I would ask Torbay Hospital and the Minister to consider the appropriateness of the issue of such cards.

Action should betaken

In my opinion action should be taken to prevent future deaths and I believe you and/or your organisation have the power to take such action.

Your response

You are under a duty to respond to this report within 56 days of the date of this report namely, 24th June 2014. I, the Coroner, may extend the period.

Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed.

Copies and publication

I have sent a copy of my report to The Chief Coroner and to the following interested persons

Dittisham, South Devon

I am under a duty to send the Chief Coroners a copy of your response.

The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the Coroner, at the time of your response, about the release or the publication of your response to the Chief Coroner

I.M. ARROW

Dated 29th April, 2014 Senior Coroner – Plymouth, Torbay & South Devon