Jane Elizabeth ALLISON · Prevention of Future Deaths report

On 02 December 2021 I commenced an investigation into the death of Jane Elizabeth ALLISON aged 84. The investigation concluded at the end of the inquest on 01 March 2022. The conclusion of the inquest was that:

Died at University of North Durham on 20th November 2021. She had been admitted to the hospital on 11th November. She had been started on the nitrofurantoin for a UTI on 28th October. This is a conventional medication. She had a total course of 10 days. There were telephone consultations with her GP on 5th and 10th November. She suffered side effects of the medication but respiratory problems were not reported or noted. On 11th November she was discovered to be suffering from catastrophic pulmonary damage.

Jane passed away in hospital after being admitted on 11th November 2021 with severe type 1 respiratory failure.

The Cause of Death provided by post mortem autopsy was 1a) Acute Pulmonary Damage
1b) Administration of Nitrofurantoin for Urinary Tract Infection. The conclusion of the Inquest was a narrative one, that she "died from the effects of prescribed medication". The following, I acknowledge: that Nitrofurantoin is a well established medication with a long history of proven efficacy; deaths associated arising from side effects are very rare; the drug BNF content published by NICE does include in the listed side effects pulmonary and respiratory issues; likewise the BNF content does say that in relation to monitoring of patient parameters "on longer-term therapy - monitor for pulmonary symptoms, especially in the elderly (discontinue if deterioration in lung function)". All this said, Jane was aged 84. She was he was extremely fit and active for her age, but this has the effect of heightening my concerns, as does that fact that she had no relevant co-morbidities. Also the course of treatment of the drug in this instance was not long, being 10 days in total, after which she died as a consequence of catastrophic pulmonary failure. Her GP, while reporting that Jane never informed her of any breathing difficulties when she consulted with her, also said that she had simply been following BNF content advice on this medication. In effect, my concern is that the BNF content had not advised to be alerted to the danger of sudden pulmonary deterioration in an elderly patient, and certainly not one who was fit and active, and not in the context of the duration of a prescribing, dispensing and administration period of only 10 days. Effectively, the BNF content did not cover the eventuality of this case in that it was deficient in providing advice as to monitoring and being alert for pulmonary failure. For the avoidance of doubt, I am including the GP medical centre as a recipient of my concerns as clinicians there may concur with them, albeit the extent of their reaction to this concern has been limited to peer group review and advice limited to within that medical practice.