Bronwyn Ann WILLIAMS · Prevention of Future Deaths report

On 25 May 2017 I commenced an investigation into the death of Bronwyn Williams, aged 68 years. The investigation concluded at the end of the inquest on 4 September 2017. I made a determination as follows.

Bronwyn Williams died on 23 May 2017 from a retropharyngeal abscess. This is a naturally occurring, albeit rare condition. She had consulted at an accident and emergency unit on 1 May 2017 and been referred to a dentist.

She saw her dentist on 4 May 2017 and was referred to a maxillofacial unit. She was due to be seen within two weeks, but the dental surgery system of referral was postal rather than electronic and then the hospital did not provide an appointment within two weeks, so she was not seen again before her death.

Her medical cause of death was:
1a septicaemia/mediastinitis
1b retropharyngeal abscess
1c gum infection
2 type II diabetes mellitus

Ms Williams saw a dentist at Kindandental on 4 May 2017, having attended the emergency unit of Homerton University Hospital on 1 May and been told to visit her dentist, complaining of pain preventing mouth opening other than to a very limited extent, and a general malaise.

Neither intra oral examination nor imaging was possible at the dental surgery, because of the extent of the trismus. The dentist therefore prescribed a five day course of antibiotics and referred Ms Williams to the maxillofacial unit of the Homerton on an urgent basis. The word urgent in this context means that an appointment should be fixed to take place within two weeks.

On 10 May, Ms Williams rang the dental surgery to say that she had seen on her copy of the referral that her road name had been misspelled and her postcode had been omitted. This was rectified and a further referral sent to the Homerton.

Ms Williams died before ever receiving her appointment.

Some matters have already been dealt with following Ms Williams’ death. However, MATTERS OF CONCERN remain as follows.

1. I heard at inquest that the urgent referral from Kindandental to the Homerton was made not by logging on to a portal, or by email, or by fax, but by post. This seems unduly slow, cumbersome and prone to mishap.

2. Following Ms Williams’ attendance at the dental surgery on 4 May, an appointment with the maxillofacial unit was made for 30 May, then cancelled by the Homerton on 23 May and re-fixed for 19 June. This date is nearly seven weeks post referral.