Peter Carr · Prevention of Future Deaths report

On 5th October 2021 I commenced an investigation into the death of Peter Carr. The investigation concluded at the end of the inquest held on the 9th,10th and 11th of October 2023.

The conclusion of the inquest was a short narrative conclusion;

Peter Carr died from a recognised complication of necessarily prescribed medication.

On the 25th of August Mr. Carr developed a rash. By the 31st most of his skin was red so he presented to the North Middlesex Hospital A&E where he was admitted by the medical team. He also had neutropenia and lymphadenopathy. The admitting doctor prescribed tazocin, a rare side effect of which is Stephens-Johnson Syndrome (SJS) / Toxic Epidermal Necrolysis (TEN.) The North Middlesex outsourced dermatology. Mr. Carr first saw a dermatologist 3 days after admission at which point there was no sign of SJS / TEN. Nevertheless skin biopsy - something every consultant dermatologist can do - was deemed necessary but the attendant dermatologist, who could have done this, did not because the company's process is to ask a plastic surgeon to biopsy. It took until the 8th for the biopsy to be taken. There was no dermatological oversight of Mr Carr's skin in the intervening time. The biopsy found evidence of drug reaction consistent with SJS. An optimum dermatology service was described by our expert as patients being seen by a consultant dermatologist and biopsied if required within 24 hours of presentation, and then watched like a hawk on a daily basis. Had this happened the emergence of SJS may have been recognised and prompted withdrawal of the culprit medication. That this level of dermatological support was not available denied Mr. Carr 'a role of the dice' - a chance of survival.

That patients who contact medical services with acute, severe, skin conditions as primary presentations, or as a component of a complex presentation, may not have consultant dermatology input and biopsy within 24 hours and ongoing consultant dermatology oversight for the duration of an inpatient stay.