Catherine Kirkham

The first concern relates to the accessibility and usability of systems used by hospital clinicians to access GP records. Evidence indicated that entries within these systems are extensive and not easily navigable, making it difficult to identify key information such as a patient’s vaccination status. The absence of a dedicated vaccination tab was highlighted as a barrier. Although some local work is underway to improve triage systems, prompting clinicians to check and document vaccination history when wound-related issues are identified, there is uncertainty as to whether such improvements are implemented consistently across hospitals nationally.  The second concern relates to deficiencies in clinical documentation and decision-making during Mrs Kirkham’s care at Tameside General Hospital. Specifically, the treating doctor failed to record a clear clinical diagnosis and did not document the administration of a tetanus booster, despite later stating he believed it had been given. Further concerns arose regarding the prescription of oral antibiotics without conducting a swallow assessment in a patient presenting with swallowing difficulties and lockjaw. This omission contributed to a subsequent choking incident at home and prevented the opportunity for hospital admission and intravenous treatment.  The third concern relates to missed opportunities across multiple points of care to identify tetanus risk and provide appropriate treatment. These include failures in the Urgent Treatment Centre, Emergency Department, and in the GP referral. Given that tetanus vaccination is typically administered in secondary care, it is essential that referrals clearly highlight suspicion of tetanus. Earlier intervention may have significantly improved the patient’s chances of survival.