Patricia Edge · Prevention of Future Deaths report

On 29ᵗʰ July 2014 I commenced an investigation into the death of Patricia Edge, 66. The investigation concluded at the end of the inquest on 3ʳᵈ December 2014. The conclusion of the inquest was that the cause of death was:-
1a) Ischaemic bowel
1b) Bowel obstruction
1c) Advanced colorectal carcinoma
II) Paracetamol liver toxicity

The conclusion was that Patricia Edge was diagnosed with diverticulitis following admission to the Royal Bolton Hospital on the 10th May 2014 with a history of abdominal pain and diarrhoea since February 2014. A colonoscopy was planned but she was readmitted on the 14th July 2014 when she was prescribed an excessive dose of paracetamol which was not corrected until the 19th July 2014. A biopsy taken on the 28th June 2014 had resulted in a report dated 2nd July 2014 confirming the presence of bowel cancer. A CT scan on the 16th July 2014 showed the cancer had spread and the bowel was obstructed. The obstruction led to the bowel becoming ischaemic - a rare condition - and her condition deteriorated and she died at the Royal Bolton Hospital on the 20th July 2014.

Patricia Edge died in Royal Bolton Hospital of bowel cancer, but an excessive dose of paracetamol dispensed between 14ᵗʰ and 19ᵗʰ July 2014 contributed to her death.

(1) The circumstances – including training of staff and Trust procedures - in which a patient could be prescribed and dispensed an excessive dose of paracetamol on the 14ᵗʰ July 2014.
(2) The apparent lack of any review of the paracetamol dose between 14ᵗʰ and 19ᵗʰ July 2014.
(3) The apparent failure to carry out blood tests between 14ᵗʰ and 19ᵗʰ July, which would have revealed/confirmed the possibility of the dose of paracetamol being excessive, again considering issues of training and procedures.