Joyce Violet Rumming · Prevention of Future Deaths report

On 14/12/2016 I commenced an investigation into the death of Joyce Violet Rumming who was born on 2nd September 1931. Violet died at The Great Western Hospital in Swindon on 12th December 2016. The Investigation was commenced as information was supplied in order to make the decision that a post mortem was required that whilst at The Great Western Hospital Joyce may have been given antibiotics in respect of which she was allergic to. I was informed that there had been a previous occasion that resulted in a reaction. As such the investigation post mortem itself was carried out at Salisbury District Hospital because of the possible conflict of interest.

Joyce had arrived at the Accident and Emergency Department of The Great Western Hospital late on the 11th December 2016, she was alert and orientated and appeared to respond clearly to questioning. She had previously been diagnosed with a chest infection in respect of which she had recently completed a course of antibiotics. The Ambulance Acute Referral Form identified that Joyce was allergic to Amoxicillin but it does not appear that this was conveyed to those in the Emergency Department room at handover. The allergy does not appear to have been picked up by the Emergency Department room staff when considering the Ambulance Acute Care Referral Form. Shortly before midnight one of the nurses in consultation with the patient's son and husband present documented an allergy to Amoxicillin on the reverse of the Care Plan. Joyce, to confuse matters had also stated to another nurse when asked that she had no allergies although there appears to have been a concern that she may have been concerned. A Doctor having checked the internal Medway System and a ED CAS card went on to prescribe Amoxicillin in respect of which Joyce apparently had an allergy following a previous reaction. It would appear that the allergy following a previous admission was recorded on the EPMA System (not used in the ED) and not on Medway which is accessible in the ED. It would appear that on the previous admission that the allergy had also been documented on the drugs chart. The Amoxicillin and Clarithromycin were administered at 01.45 on the 12th December 2016 and sadly Joyce passed away just over ½ hour later. Having made further enquiries the cause of death highlighted that Joyce's death was due to respiratory failure but that it did not appear to be related to an allergic reaction to the Amoxicillin. It will shortly be the case that the investigation will be discontinued on the basis that the cause of death appears to be natural and ████████ suggests the following as a cause of death which I have no reason to reject:-

1a) Type II respiratory failure and respiratory acidosis
1b) Large sliding hiatus hernia
2) Chronic asthma, recent lower respiratory tract infection and coronary artery atherosclerosis.

Helpfully a Route Cause Analysis was undertaken which highlighted as a care service delivery problem the fact that an antibiotic, Amoxicillin, in respect of which it was believed that Joyce was allergic to following a previous allergic reaction had been given to her shortly before her death. The Route Cause Analysis in relation to items (bullet points) under contributory factors documents a number of areas that give rise for concern. It essentially amounts to right hand not communicating with the left hand in that for example unless a Doctor looks in a specific location due to issues as regards the communication between various software packages that the existence of an allergic marker could be missed as was the situation in relation to Joyce's case. A number of recommendations have been highlighted which have been documented at items 1-4 in the action plan. I share the concerns highlighted by the Route Cause Analysis and the purpose of this Regulation 28 Report is to enable a mechanism whereby your Trust feeds back both to myself and to the family the results of the recommendations and provides details in respect of what changes will be made and if changes cannot be made as to why they cannot be made. Proceeding in this way will allow the family to secure a full death certificate following discontinuance which will take place a few days after this Regulation 28 Report is sent out. I have attached for ease of reference Appendix A which contains the 4 recommendations.