Source · Prevention of Future Deaths
Carol Ann Gibson
Ref: 2013-0183
Date: 12 Oct 2013
Coroner: Nicholas Rheinberg
Area: Cheshire
Responses identified: 0 / 2
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A GP ignored a critical adverse drug reaction alert, exacerbated by a culture of 'alert fatigue' and dismissive attitudes towards patient safety warnings within the medical practice.
Date
12 Oct 2013
56-day deadline
7 Dec 2013 est.
Responses identified
0 of 2
Coroner's concerns
A GP ignored a critical adverse drug reaction alert, exacerbated by a culture of 'alert fatigue' and dismissive attitudes towards patient safety warnings within the medical practice.
View full coroner's concerns
1. ignored a warning alert in the medical records that his patient had suffered an adverse reaction to nitrofurantoin without checking the nature of the adverse reaction and issued a prescription for the drug regardless.
2. A letter dated 3rd November 2008 was sent by a consultant to at Castlefields Health Centre identifying that the interstitial lung disease from which
3. on commenting on alert warnings, said that most are “trivial, spurious, irrelevant or just wrong”, identified a phenomenon that he described as alert fatigue and further stated that colleagues within the practice had admitted that they “may well have done the same in my situation”.
I am concerned that if comments correctly describe the attitude within his medical practice to patient safety alerts this is a matter of considerable concern and warrants investigation by you to ensure first of all that the practice has a robust system in place for posting such alerts, secondly that such alerts when posted, correctly and sufficiently identify the problem and thirdly that doctors and medical staff within the practice have full understanding and training to respond to such alerts in an appropriate manner.
2. A letter dated 3rd November 2008 was sent by a consultant to at Castlefields Health Centre identifying that the interstitial lung disease from which
3. on commenting on alert warnings, said that most are “trivial, spurious, irrelevant or just wrong”, identified a phenomenon that he described as alert fatigue and further stated that colleagues within the practice had admitted that they “may well have done the same in my situation”.
I am concerned that if comments correctly describe the attitude within his medical practice to patient safety alerts this is a matter of considerable concern and warrants investigation by you to ensure first of all that the practice has a robust system in place for posting such alerts, secondly that such alerts when posted, correctly and sufficiently identify the problem and thirdly that doctors and medical staff within the practice have full understanding and training to respond to such alerts in an appropriate manner.
Report sections
Investigation and inquest
On 10th August 2012 I commenced an investigation into the death of Carol Ann Gibson aged 65. The investigation concluded at the end of the inquest on 8th August 2013. The conclusion of the inquest was that the deceased died as a result of an adverse reaction to the drug nitrofurantoin and that her death was due to misadventure.
Circumstances of the death
The deceased had a history of severe urinary tract infections with severe symptoms of both a physical and mental nature. In 2007 her General Practitioner having taken advice from a consultant prescribed the drug nitrofurantoin on a prophylactic basis. The deceased subsequently suffered from serious lung disease as an adverse reaction to the drug and when in 2008 this was recognised as a probability, the prescription of the drug was discontinued and an alert was subsequently posted in the patient’s medical records. In 2011 the deceased again suffered a urinary tract infection. failed to heed the alert within the medical records and on 10th August 2011 issued a prescription for nitrofurantoin. issued a further prescription for the drug on 12th April 2012 and on 26th July 2012 a nurse practitioner within the medical practice also issued a prescription for the drug. On 1st August 2012, without examining the patient, a final prescription of nitrofurantoin was issued. On 8th August 2012 the deceased died at her home at Palacefields, Runcorn as a result of an adverse reaction to nitrofurantoin.
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Report details
- Reference
- 2013-0183
- Date of report
- 12 October 2013
- Coroner
- Nicholas Rheinberg
- Coroner area
- Cheshire
Responses identified
Responses identified
0 of 2
2 responses not yet linked
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 7 Dec 2013 (estimated).
Sent to
- Castlefields Health Centre
- NHS England