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Investigation and inquest
On 25.4.19, an investigation into the death of Sandra Dawne Scott was commenced. The investigation concluded at the end of the inquest on 5.4.19. The conclusion of the inquest was a narrative conclusion, copy attached.
Circumstances of the death
On the 18th April 2019 Royal Hallamshire Hospital prescribed Mrs Scott Trimethoprim for a urine infection. They also did a urine test.
On the Same day her GP saw the results of an earlier urine test showing a urinary tract infection which would not be receptive to treatment with Trimethoprim. The GP therefore advised Mrs Scott that she would prescribe Amoxycillin.
The GP issued the prescription electronically to be collected at a pharmacy nominated by Mrs Scott. The GP then amended the system a few minutes later so that future prescriptions would not automatically be sent to that chemist. Unknown to the GP, the change meant that the prescription issued would now not be available for download by the original pharmacy.
The results of the hospital urine test were available on the 20th April 2019 but were not acted upon at this point.
Mrs Scott was admitted to Royal Hallamshire Hospital with worsening symptoms on the 22nd April 2019. She was appropriately treated at this point. However, she deteriorated and sadly died on 23rd April 2019.
Coroner’s concerns
During the inquest, evidence showed:-
1. The GP issued a prescription to a nominated chemist, but a few minutes later put the system details back to what they were before the prescription was issued. Unknown to the GP these changes meant the prescription was no longer available for download by the chemist.
2. This resulted in the patient not getting required medication.
3. The evidence was that the GPs colleagues were also unaware of this peculiarity of the system.
4. Other medical professionals are also likely to be unaware.
5. The Royal Hallamshire Hospital received the results of a urine test on the 20.4.19 but did not act upon them as the patient had been discharged.
6. The evidence was that had the patient received the medication prescribed by the GP or indicated by the hospital results, then she would not have died when she did.
7. There is the potential for wide learning from this tragic case.
Information checked against the published report and official responses