DAPHNE JOAN PENN · Prevention of Future Deaths report

At the conclusion of the inquest into the very sad death of DAPHNE JOAN PENN, I recorded a narrative conclusion that ‘Mrs Penn died from pneumonia occurring against a background of pre-existing significant natural disease and possibly due to aspiration in the final deterioration. Her last illness leading to her hospital admission was likely to have been multifactorial and contributed to, at least in part, by an inadvertently rapid reduction in the dose of her long term steroid therapy’. The cause of death was found to be: 1a Pneumonia.

Mrs Daphne Penn had been transferred from West Suffolk Hospital to Newmarket Community Hospital for rehabilitation and sadly died following her subsequent readmission to West Suffolk Hospital, her condition having deteriorated at Newmarket Community Hospital. She suffered from various pre-existing significant natural disease processes for which she took medication, including long term steroids, and there were problems associated with the provision of these steroids while she was a patient at Newmarket Community Hospital.

The inquest heard that, as well as the significant benefits that long term steroids can clearly bring to some conditions, there are also well recognised and significant potential risks including side effects such as (i) agastro intestinal bleeding; (ii) suppression of normal steroid production necessitating, when prescribed doses have to be reduced medically, slow and gradual dose reduction and the avoidance of sudden drops in the dose of steroids given; and (iii), because of the long term suppression by prescribed long term steroids of the glands producing steroids in patients naturally, the need for prescribed doses to be increased where there is intercurrent illness, known as the ‘Sick Day Rules’.

The inquest also heard that a more rapid steroid reduction rate than that suggested by the original consultant was initiated, although the clinical reasons for this were given by the second consultant in respect of the need to balance benefits against the risk of further gastro-intestinal bleeding here; that there was a delay transmitting to relevant medical staff concerns about her condition expressed to healthcare staff by Mrs Penn’s very supportive family, who clearly understood the issues related to steroids well; and that there was also an inadvertent additional decrease in the steroid dose prescribed following a prescribing error by a general medical practitioner who misread the intended steroid dose when rewriting the drug chart.