Peter Arthur Rowe · Prevention of Future Deaths report

On 11th February 2016 an investigation was commenced into the death of Peter Arthur Rowe who died while an in-patient at Stepping Hill Hospital, Stockport on 8th February 2016, having been admitted on 1st February 2016.

The investigation concluded with an inquest held on 8th June 2016.

Medical cause of death 1a) Multi-organ failure
1b) Sepsis
1c) Toxic epidermal necrolysis

II Psoriasis
Cerebrovascular accident

In answer to the questions ‘how, when and where’ the findings were as follows,

On the 26th January 2016 Peter Arthur Rowe was admitted to Manchester Royal Infirmary for day case general anaesthesia for removal of a lipoma from his back. Co-amoxiclav was administered as a prophylactic antibiotic, notwithstanding the GP referral letter stated a penicillin allergy of 2004. Mr and ████████ stated that they were unaware of any allergies upon being asked that specific question in the pre-operative consultations and assessments. The Adult Inpatient Prescription and Administration record, dated 26th January 2016, notes in the section Allergies/Intolerances a penicillin and aspirin allergy which is then crossed out and the box signed as no known allergies. Following discharge Peter Arthur Rowe developed a red scaly rash which worsened and on the 1st February 2016 he was admitted to Stepping Hill Hospital with an initial diagnosis of an infected (pustulated) psoriasis, which was changed the following day to Toxic Epidermal Necrolysis, the likely pathogenesis of which was the administration of prophylactic co-amoxiclav on the 26th January 2016. Peter Arthur Rowe continued to deteriorate and died on the 8th February 2016.

CONCLUSION: Misadventure

The circumstances are as described above.

1. That despite the GPs referral letter stating an allergy to penicillin, a penicillin based prophylactic antibiotic was prescribed and administered.

2. The fact of the GPs referral letter stating an allergy to both penicillin and aspirin appears to have been transferred on to the Adult Inpatient Prescription and Administration record and then deleted, albeit it is not clear by whom and when.

3. On the evidence heard at the Inquest Mr Rowe suffered from very poor memory following his stroke in 1993. In the premises I am concerned that negative answers to questions regarding any allergies stated to have been put to both Mr Rowe and ████████ were accepted at face value when,

a) Mr Rowe suffered from significant memory loss and decreased cognitive function, and

b) When ████████ would not necessarily have known of her husband’s allergy (and indeed did not).