Tripta Rani KUMAR · Prevention of Future Deaths report

On 30th August 2012 I commenced an investigation into the death of Tripta Rani KUMAR,69 years. The investigation concluded at the end of the inquest on 4th September 2013. I concluded with the narrative “The deceased undertook routine, planned vaginal hysterectomy and anterior repair on 21st August 2012 before being discharged on 23rd August. She was readmitted on the 24th August 2012 with overwhelming sepsis as a result of bowel perforation likely incurred during the procedures carried out on 21st August. She died as a result.” The medical cause of death was 1a. Multiple Organ Failure, 1b. Organising Peritonitis, 1c. Perforation of Large Bowel (repaired), II. Old Empyema of chest

1. The deceased had a planned hysterectomy for a prolapse on Tuesday 21st August and was discharged on 23rd August 2012.

2. She was readmitted on the 24th August 2012 complaining of abdominal pain and found to have a perforated bowel.

3. Hartmans procedure completed but she was septic by this stage. Maximum treatment continued post operatively in ITU but she suffered a cardiac arrest on the 25th August 2012.

4. CPR was given but she died despite efforts made.

In the emergency department, during the course of treatment given on the 24th August 2012, the deceased was attended to by an ST4, doctor in Obstetrics and Gynaecology. The doctor documented the likely diagnosis, requested an urgent CT scan and prescribed intravenous antibiotics in the form of Tazocin. Tazocin contains two active ingredients, Piperacillin, which is a penicillin type antibiotic and Tazobactum which is a medicine that prevents bacteria from inactivating Piperacillin.

Evidence from the family of the deceased, confirmed by ████████ (Consultant in Accident and Emergency), revealed that the notes clearly showed that the patient had a penicillin allergy. The family of the deceased also confirmed in court that their mother was wearing a band on her wrist which confirmed the penicillin allergy. ████████ further confirmed that the entry in the notes that said ‘penicillin allergy’ had been crossed out and the note ‘nil allergies’ had been entered instead. This was in handwriting but with no signature to confirm who had written the note.

The grave danger is that, although not relevant in this particular case, giving someone penicillin who was allergic to that penicillin could easily have resulted in an anaphylactic shock which, in turn, could have resulted in death.