Alec James MATHIAS · Prevention of Future Deaths report

On 7th October 2014 I commenced an investigation into the death of Alec James MATHIAS, 78 years old. The investigation concluded at the end of the inquest on 24th June 2015. The conclusion of the inquest was Misadventure with the Cause of Death being –

1a – Liver Failure
1b – Flucloxacillin Induced Cholestatic Liver Injury
1c – Treatment for Cellulitis of the Left Index Finger
II – Radiation Proctitis following Radiotherapy for Carcinoma of the Prostate

Mr Mathias suffered a whitlow of his Left Index Finger in June/July 2008 during which time he was treated with Flucloxacillin.

He was admitted to the Royal Devon and Exeter (Wonford) Hospital on the 10th September 2008 with a presumptive diagnosis of painless obstructive jaundice under ███████
████ following a GP letter dated 9th September 2008 ███████
Consultant Gastroenterologist (see p.4 statement of ███████████████████████
dated 29.01.2015).

It was found that he had suffered drug induced jaundice and the Flucloxacillin was stopped (further doses having been given while he was an in-patient).

There is no record of a discharge summary being sent to Mr Mathias’s GP or that he had suffered a reaction to the Flucloxacillin and that this had been the agreed cause of his liver problems.

Mr Mathias suffered further infection of the index finger in August 2014 and was again prescribed Flucloxacillin by the GP practice nurse, which proved fatal – see Record of Inquest.

I received evidence from ███████████ September 2008 admission and ███████
and ███████████ regarding the 22nd August 2014 admission and it is clear
that not only was no discharge letter sent to the GP in 2008 alerting the practice to Mr
Mathias's idiosyncrasy regarding Flucloxacillin but there was no highlighting of the
hospital notes that he had an allergy or would suffer a reaction if given Flucloxacillin.

The administration of Flucloxacillin has caused Mr Mathias’s death.

(1) Discharge letters have not been sent to the patients GP in a case where a dangerous side effect to treatment has been noted
(2) That the hospital has not highlighted its own records with vital information on drug sensitivity discovered and diagnosed on an in-patient.