Carol Buchanan · Prevention of Future Deaths report

On the 1st June 2017 I commenced an investigation into the death of Carol Buchanan, aged 27. The investigation concluded at the end of the inquest on the 6th October 2017.

The medical cause of death was:-

Ia Coronary Artery Thrombosis
Ib Ischaemic Heart Disease

II Urosepsis and Rhabdomyolysis (clinical)

My conclusion as to the death was “Misadventure”.

The deceased had a history of previous stroke, morbid obesity, chronic obstructive pulmonary disease, cerebral vascular disease and asthma. She had been prescribed medication by her general practitioner. On the 27th April 2017, the deceased was admitted to hospital following a fall. She was prescribed medication to treat diabetic neuropathy and was being investigated by her general practitioner for a possible serious ongoing urinary tract infection. On the 27th April 2017, the deceased was admitted to the Royal Bolton Hospital with a history of a fall. Following final results of the medication to treat diabetic neuropathy and to treat a possible serious ongoing urinary tract infection, the deceased was admitted to the hospital. On the 27th April 2017, she was prescribed the medication to treat diabetic neuropathy and to treat a possible serious ongoing urinary tract infection. The medication was tested at the hospital as a possible serious ongoing urinary tract infection. The investigation of her prescription was incomplete and contributed to her deterioration. The combined prescription of Simvastatin and Traconazole caused a serious complication of a cross reaction leading to Rhabdomyolysis and muscle necrosis. The deterioration in her condition was recognised by the medical team on the 16th May 2017 when the consequences of the cross reaction of prescriptions was diagnosed and the deceased was being admitted to the intensive care unit. Despite active treatment and management thereafter, the condition of the deceased further deteriorated and on the 26th May 2017 she died.

1. The prescription of Itraconazole was undertaken at the Royal Bolton Hospital’s Respiratory Clinic’s without the consultation or cross referencing information with the Summary Care Record.

2. In the absence of access to such documentation, clinicians are instructed to make use of the information provided verbally by the patient/family or carer which in the event of a patient’s presentation can be incomplete or inaccurate. An extensive prescription regime can give rise to incomplete or inaccurate relevant prescription history.

3. The prescription of Itraconazole on the 27th April 2017 was not typed up into relevant records either by way of a “GP clinic letter” or by way of a timely effective prescription.

4. The very serious interaction between Itraconazole and Simvastatin which contributed to the cause of death was not appreciated.

5. In the Division of Tracheobronchial and Sinusitis, it was noted that the correct diagnosis was assisted with further information from the patient and family from the 21st May 2017 and the family had repeatedly presented the specific information of circumstances that demonstrates that the concerns were not noted adequately:
a. The importance of the history not appreciated upon;
b. Missed opportunities between and 27th May 2017 to act on the history not appreciated or acted upon;
c. Delay in implementing delivery of fluid balance monitoring; and
d. delay in specific diagnosis of the underlying cause of the patients presenting symptoms.