Philip Geoffrey Day · Prevention of Future Deaths report

On 22nd April 2022 I commenced an investigation into the death of Philip Geoffrey Day. The investigation concluded on the 19th October 2022 and the conclusion was one of Narrative: Died from complications of necessary medical therapy. The medical cause of death was 1a) Multi-organ Failure; 1b) Neutropenic Sepsis and Colitis; 1c) Methotrexate treatment for Psoriatic Arthritis

Philip Geoffrey Day had psoriatic arthritis. He was prescribed methotrexate for his condition. Blood tests on 10th April 2022 showed that he had neutropenia and a raised CRP. He was advised to go to hospital due to the risk of neutropenic sepsis a rare but recognised complication of methotrexate. He went to Stepping Hill Hospital. Triage occurred approximately 50 minutes after his arrival and he was reviewed by a doctor at 04.56 almost 7 hours after his arrival. Antibiotics and fluids were prescribed for his neutropenic sepsis. This was outside the recommended timeliness guidelines. He was admitted to Stepping Hill Hospital and continued to be treated for neutropenic sepsis. He developed ileitis and colitis. He continued to be treated. On 15th April the combination of the neutropenic sepsis and inflammation led to a cardiac arrest and multi organ failure. He died at Stepping Hill Hospital on 15th April 2022.

1. When Mr Day arrived in ED, it was struggling to cope with a large backlog. Waiting times on that night /morning were significant. Triage wait times were approximately 1 hour. The time to see a doctor rose through the night to 7 hours and 38 minutes by 6am. The inquest heard that this was due to sheer volumes and that this is a situation that still arises. The impact is a delay in patients being seen, assessed and treated promptly;

2. In relation to Mr Day the inquest heard that the community OOH Doctor had correctly recognised the risk of neutropenic sepsis and had rung through to speak to a doctor at the hospital. At the inquest there was no documentation to assist in tracking that conversation or any evidence it had been recorded or acted on. It was clear from the evidence at the inquest that the sharing of information between community clinicians and secondary care was important and that there appears to be no recognised way for this to happened due to varied IT systems and no national recommendations for best practice in this scenario. As a consequence vital information is not available to ED teams.

3. The Inquest heard that Mr Day’s first EWS score in ED was 2. He did not trigger on EWS for sepsis. However the blood tests in the community had shown a very low neutrophil level and a rising CRP. Had those factors been recognised along with his immunosuppression then he would have been treated under the neutropenic sepsis pathway earlier. The evidence suggested that there is a lack of awareness of the guidance and red flags for neutropenic sepsis which delays treatment. Greater awareness and triage questions that prompt for neutropenic sepsis would reduce the risk of neutropenic sepsis symptoms being missed at triage.