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Investigation and inquest
On 2nd September 2015 I commenced an investigation into the death of Alwyn Ann Head, 70 years. The investigation concluded at the end of the inquest on 21st March 2016. The conclusion of the inquest was that Alwyn Ann Head died from a recognised complication of a consented and necessary procedure
Circumstances of the death
Alwyn Head was admitted to Medway Maritime Hospital on 10th August 2015 following two falls in which she fractured her left femur at the site of a prosthesis which had been previously placed in Belgium following a similar fracture after a fall. She underwent surgery and approx. 12 days post-operatively a wound infection was noted which was later determined to be MRSA. She was given antibiotics the following day and two days later underwent a debridement and washout. She deteriorated post-operatively requiring increasing inotropic support. She died on 20th August 2015
Coroner’s concerns
(1) That Mrs Head had a history of MRSA was not established prior to surgery despite opportunities in 3 different hospital departments to obtain this information from Mrs. Head or her family
(2) Prophylactic Teicoplanin was not provided pre- or post-operatively even though the results of an MRSA screen would not have been available at the time of surgery (MRSA –ve written on pre-op form erroneously)
(3) A post-operative wound care plan was not instituted contrary to NICE guidelines
(4) There was no evidence of the surgical wound having been inspected by nursing staff or doctors between the 13th August and 25th August 2015
(5) Entries in the nursing notes relating to dressing and wound were meaningless and would not assist a determination of whether there was deterioration in the wound
Information checked against the published report and official responses