Joan Margaret Sanderson · Prevention of Future Deaths report

On 15ᵗʰ June 2020 I commenced an investigation into the death of Joan Sanderson. The investigation concluded on the 4ᵗʰ September 2020 and the conclusion was one of Narrative: Died from complications of a surgical procedure following an accidental fall.

The medical cause of death was 1a) Cardio pulmonary arrest; 1b) MRSA positive left hip metalwork infection; II) Dementia, Diabetes mellitus

Joan Margaret Sanderson had an accidental fall. She was admitted to Tameside General Hospital where a displaced intertrochanteric fracture of the left hip was diagnosed. She was operated on. She developed an infection which was identified as MRSA. She deteriorated and died on 15th June 2020 at Tameside General Hospital.

The inquest heard evidence from the Trust that following her death they had carried out a RCA to understand what learning could be taken from Mrs Sanderson’s death. A key piece of learning was identified, as patients being admitted for orthopaedic surgery, from a care home or those that have had a previous positive MRSA result should have a routine swab sent for MRSA on admission to hospital.

In this case a swab was not collected as that was not standard at that time. Surgery would not be held up awaiting the outcome but it would have allowed earlier identification of MRSA which could impact the outcome in another case where emergency surgery is required and there is an infection post operatively. Patients admitted for elective surgery have a MRSA swab collected 12 weeks prior and receive decolonisation treatment for a positive MRSA result prior to surgery.

The inquest was told this change had been rolled out in the trust and was seen as wider learning that could prevent future deaths within the NHS.