Mrs Ann Patricia Ellen Schuetz · Prevention of Future Deaths report

On the 04/07/2018 I commenced an investigation into the death of Mrs Ann Patricia Ellen Schuetz. The investigation concluded at the end of an inquest on 24/11/2020. The medical cause of death was determined to be:-
1a Multi organ failure
1b Hypoxic cardiac arrest
1c Angioedema secondary to Angiotensin-converting enzyme inhibitor
2 Large brain infarct

Mrs Ann Patricia Ellen Schuetz died on 26th June 2018 at NGH as a result of an allergic reaction to Ramipril, medication prescribed for hypertension.

Mrs Schuetz was seen at Northampton General Hospital (NGH) and by her GP practice numerous times between 2015 - 2018. Several of the attendances to hospital were due to angioedema which on some of the attendances was noted to be a reaction to Ramipril, the Angiotensin-converting enzyme inhibitor medication she was taking to manage her high blood pressure. Despite this diagnosis, this information was not added as an allergy on either Symphony, ePMA or on the Electronic Discharge Notification forms. It was also not coded as an allergy on the GP’s electronic system. During an admission to hospital in November 2017 Mrs Schuetz became hypertensive. Ramipril was re-started as there was no contraindication in the medical notes. The GP practice then continued to prescribe the Ramipril as it was not coded as an allergy on the GP system. In June 2018, Mrs Schuetz had another allergic reaction and was admitted to NGH. Despite intensive treatment and interventions, Mrs Schuetz sadly died on 26th June 2018.

In the present case, the allergy was not recorded in the appropriate places in the relevant electronic systems. A contributing factor was that that primary and secondary care have a number of different electronic systems in place to manage patient medical information including:-

1. Symphony – Emergency Department system
2. EDN – Electronic Discharge Notification system
3. ePMA – Electronic prescribing system
4. SystemOne – Electronic GP documentation system
5. CAMIS – Overview system which holds such details as ID and all attendances including outpatient

One of the root causes according to the Trust’s Investigation report was “the fact that the electronic patient systems used in primary and secondary care did not have the ability to share information and therefore the updated allergy information was required to be inputted manually into each system….”

The Trust is continuing to explore the feasibility of having regional central medical records but it is not known if any other Trusts are doing the same.

The Investigation report also states that “The CAMIS system currently does not have anywhere to record a patient’s allergies. If a change is to be made to the CAMIS system, this would need to be changed nationally”.