Margaret Elaine Wright · Prevention of Future Deaths report

On 31st December 2014 I commenced an investigation into the death of Margaret Elaine Wright, 72 years. The investigation concluded at the end of the inquest on 7th May 2015. The conclusion of the inquest was that Margaret Elaine Wright died of a complication of surgery for hepatocellular carcinoma which carcinoma was itself a complication of previous blood transfusions.

Between the 7th January 1969 and the 21st January 1969 Margaret Elaine Wright was transfused 11 units of blood at Bury General Hospital. In 2012 she was diagnosed to have hepatitis C and to have developed liver cirrhosis. In 2014 she was diagnosed to have developed hepatocellular carcinoma. These were consequent upon the aforementioned blood transfusions having been contaminated. On the 7th of November 2014 she underwent surgery for hepatocellular carcinoma at the Manchester Royal Infirmary. She was discharged from that hospital on the 11th December 2014. Thereafter her condition gradually deteriorated until on the 17th of December 2014 her husband contacted his Doctor’s practice and requested a home visit. The Doctor doing home visits on that day was unaware of Mrs Wright’s recent surgery since the practice had not received a discharge summary from the hospital. The Doctor therefore visited other patients during the afternoon of the 17th of December, which meant that he had insufficient time to visit Mrs Wright until the evening. Before the Doctor arrived Mrs Wright collapsed. An ambulance was called and she was admitted to hospital, where she died on the 23rd December 2014.

(1) The Doctors did not at that time telephone patients or their families when a home visit had been requested to obtain further information about the patient’s situation. Had that happened in this case Mrs Wright would have received a priority visit, although there was no evidence that this would have affected the outcome. Evidence was given that since Mrs Wright’s death a system of a Doctor telephoning patients or their families prior to visiting had been introduced, both in the Doctors practice in question and in the local area. Evidence was given that this best practice should be drawn to the attention of the Secretary of State for Health in order to prevent future deaths.