Mrs Patricia McAdam · Prevention of Future Deaths report

On 2nd June 2018 I commenced an investigation into the death of Mrs Patricia McAdam.
The investigation concluded at the end of the inquest on 13th March 2020. The medical
cause of death was:

1a. Multi-Organ failure
1b. Septic Shock
1c. Infected leg ulcers (with osteomyelitis) and peripheral vascular disease
2. immobility due to rheumatoid arthritis and low body mass index (cachexis)

The conclusion of the inquest was that Patricia Mcadam died suffering sepsis caused by
peripheral vascular disease and immobility.

The deceased was known to be wheelchair bound due to her arthritis and was a smoker
with peripheral vascular disease. She was cared for at home by her daughter. On 31st
May 2018 she was admitted to Croydon University Hospital in a state of extremis. Her
pressure sores and leg ulcers were Grade 4. She died of sepsis eleven days later on 11th
June 2018. Post mortem examinations have identified old rib fractures, which could have
happened with trivial force. There is some evidence that the deceased refused care in the
years preceding her state of extremis in May 2018. She was a frail, elderly lady who had
not seen her GP for a long time and the District Nurses since 2015. There is a natural
causes element to her death, particularly in relation to her arthritis and peripheral vascular
disease.

Mrs McAdam was known to be wheelchair bound due to arthritis and was a smoker with
peripheral vascular disease. She was cared for at home by her daughter. She died at
Croydon University Hospital on 11th June 2018 from complications associated with infected
leg ulcers. She had not been seen by a GP since 13th July 2015. Although there was a
large element of the patient herself declining contact and care from healthcare
providers, her repeat prescriptions (Oramorph, co-codamol, Amitriptyline and
Furosemide) continued despite there being no obvious regular attempt, or any, to assess
and check up on her.

Caring for patients refusing patient care is obviously challenging. However, I am
concerned that there is a system in place in the future to ensure that these patients are
regularly assessed, even if that assessment bears no fruit due to a competent patient
declining help. I am reassured that the GP practice has put into place a system now
whereby these patients do not get forgotten but this report asks for confirmation of such a
system.