Michele Brenda Duckworth · Prevention of Future Deaths report

On 06/08/2020 I commenced an investigation into the death of Michele Brenda Duckworth, aged 57. The investigation concluded at the end of the inquest on 9th February 2021. The conclusion of the inquest was that death was due to natural causes against a background of complications from necessary immunosuppression therapy and long term urinary catheter resulting from a road traffic collision.

The deceased had a medical history of paraplegia from a spinal cord injury due to a road traffic collision in 1984. This resulted in a requirement for intermittent self-catheterization and she suffered recurrent urinary tract infections. She had end stage renal failure and underwent a renal transplant in September 2015 where she was then placed on immunosuppression therapy. She developed chronic diarrhoea and was under investigation at the Royal Stoke University Hospital, Stoke-on-Trent. She was required two hospital admissions in October and December 2019 due to worsening of this condition. She was seen by the gastroenterology department on both hospital admissions and was referred for an outpatient appointment for a further investigation but the procedure was cancelled because of her clinical condition. She had suffered weight loss and malnutrition and had been referred to the dietician during her hospital admissions where supplements were offered and trialled in October but NG feeding had been refused. She declined supplements in the December admission and had capacity to make this decision. She was admitted to the renal ward of the University hospital on the 10th February 2020 with profuse diarrhoea and low blood pressure. She was treated with antibiotics, fluids and electrolyte replacement, blood transfusion, nutritional support and pancreatic enzyme supplements. She was clinically stable until the 21st February but then suddenly deteriorated on the 22nd February where she developed a temperature. Previous rectal swabs had shown that she was colonised with ESBL but current rectal swabs were negative. She was treated for sepsis with Tazocin but Trust guidelines in these circumstances required a different antibiotic. This did not contribute to her subsequent death. She was transferred to the intensive Care Unit but was not suitable for ventilation. Despite further treatment, she deteriorated and died at 3.10pm on the 23rd February 2020. A blood culture taken on the 22nd February found Escherichia Coli bacteraemia which was resistant to Tazocin. The result of the blood culture was not known until after she had passed away. A post mortem examination found that death was due to sepsis from Escherichia Coli bacteraemia of an unknown source.
Sepsis (Escherichia Coli bacteraemia) of unknown source.

[BRIEF SUMMARY OF MATTERS OF CONCERN]
(1) The deceased was incorrectly prescribed Tazocin when she was previously colonised with ESBL. It was initially prescribed when she was on the renal ward and was continued when she was transferred to the Intensive Care Department. The antibiotic given in that context was not the antibiotic suggested in the trust guideline, and it was missed after several medical reviews.