Darren John Goddard · Prevention of Future Deaths report

On 30th April 2019 I commenced an investigation into the death of Darren John GODDARD. The investigation concluded at the end of the inquest on 22nd January 2020.

The medical cause of death provided by the Royal Glamorgan Hospital was:

1(a) Multi-organ Failure;
and
1(b) Sepsis (escherichia coli) following prostatic biopsy 1/4/19.

The Coroner’s conclusion at the end of the Inquest was a Narrative Conclusion:

The deceased died from a recognised complication of sepsis following an elective medical procedure. Medical intervention failed to recognise the urgency required for the diagnosis and treatment of sepsis although the impact of this upon the deceased's survival is unclear.

The family’s concerns at inquest were:
i) Advice received prior to consenting to the Trans Rectal Ultrasound biopsy (TRUS) procedure was that sepsis was a rare post-procedure occurrence i.e. the consent form stated a risk of “rarely sepsis“ (Sepsis is a recognised complication following TRUS biopsy occurring in less than 1% of biopsies despite antibiotic cover). Conversely, transient flu-like symptoms were stated as more commonly experienced. This information led Mr. ████████ Goddard to believe the shivers and symptoms he experienced on 1st April 2019 post-operatively were, more likely than not, to be the more common adverse effects of flu-like symptoms rather than the more insidious symptoms of sepsis. The family consider emphasis of flu-like symptoms was misleading as they can overlap with the grave symptoms of sepsis thereby minimalizing patient concern and avoiding seeking prompt intervention.

ii) Subsequent to Mr. Goddard’s death, the family question how this data i.e.1% is generated and whether or not it is a reliable reflection of the incidence of sepsis following TRUS.

iii) On 29 March 2019, prior to his TRUS procedure, Mr. Goddard was provided a prescription for 4 doses of the antibiotic Ciprofloxacin 750mg. This was considered as being contra-indicated for Phenytoin, the anti-epileptic medication prescribed long-term to Mr. Goddard. In the event, and following discussion between the Pharmacy, the Urology Consultant and Nurse Practitioner, it was agreed Ciprofloxacin was safe to be taken with Phenytoin. The British National Formulary does not list this antibiotic as a contra-indicated medication for Phenytoin.

iv) Mr. Goddard received his antibiotic prescription which he took as prescribed in order to be provided antibiotic prophylaxis for the procedure he was to undergo. The family now have concerns whether the interaction between Phenytoin and Ciprofloxacin 750mgs which was subject of discussions between the pharmacist and Consultant related to any diminished efficacy of the antibiotic.

v) Mr. Goddard underwent TRUS on 1 April 2019 at 1100 hours. He was advised the procedure had been conducted without complication and was discharged at 1300 hours with the warning that he may suffer flu-like symptoms and advised to drink plenty of water. He was discharged from the post-op recovery unit after demonstrating he could tolerate fluids; could produce urine; and had no per rectal bleeding. He was observed for approximately 1 hour post-operatively whereas the recommended observation period was for longer. Had Mr. Goddard been observed for the full recommended period of time his family consider that his early symptoms of sepsis would have been noted in the recovery unit with a good chance of rapid diagnosis and treatment.

vi) The following day, on 2nd April 2019 Mr. Goddard suffered a headache, shaking became incoherent, was bleeding per rectum and in a state of collapse. ████████ fearing sepsis rushed her husband to A&E at Royal Glamorgan Hospital. A full account of the TRUS procedure and risk of sepsis was provided to the Nurse at Triage yet there was no sense of urgency with progressing Mr. Goddard for antibiotic treatment and significant delays occurred with being reviewed by a doctor and being administered antibiotics (a delay of 1 hour 40 minutes later than required with the current sepsis 6 management bundle). These delays represented missed opportunities for successfully treating Mr. Goddard.

vii) There was a further significant delay (around 7 hours) in escalating Mr. Goddard for Critical Care by which time he was at risk of heart failure, sepsis and septic shock from a high lactate level (risen to 20).

viii) Although colloidal IV fluids were administered in A&E these were not the recommended fluids for treatment of hypovolaemic shock.

These were recorded as :-

Darren John Goddard 52 years underwent an elective, trans-rectal ultrasound of his prostate gland. A risk associated with the procedure is sepsis. The following day he became acutely unwell and was admitted to the Royal Glamorgan Hospital where upon sepsis was diagnosed but with significant delays with providing intervention. When treatment was provided it was not always the recommended treatment.

Medical intervention failed to improve his condition and he passed away on 18 April 2019.

The Inquest focused upon:-

a. The practices & procedures of the elective surgery of TRUS and information provided concerning sepsis as an adverse effect.

b. Failures within A&E at triage through to critical care to expedite appropriate treatment for sepsis even though warnings of the lethality of sepsis was advertised through public warning notices displayed in the A&E department.

(1) TRUS elective surgery ‘consenting’ and information provision (oral and in written format) places a misleading emphasis on flu-like symptoms as adverse effects.
(2) The accuracy of the 1% risk of sepsis incidence provided.
(3) Premature discharge post-operatively from the recovery unit with the missed opportunity to recognise the adverse effect of sepsis when they occurred.
(4) The failure at triage to escalate this referral to seeing a doctor within 10 mins of admission.
(5) Subsequent failure to provide timely and appropriate fluids and antibiotics.
(6) Delay in admission to Critical Care.