Mr Edward Hearn · Prevention of Future Deaths report

I opened an inquest into the death of Mr Edward Hearn, who died on 5th February 2018 in King’s College Hospital, (0395-18). An investigation was opened on 12th February 2018 and was concluded on 17th April 2019. A reserved judgement was delivered on 8th May 2019.

The medical cause of death was:
1a Sepsis
1b Bronchopneumonia
1c Multiple myeloma (treated with Carfilzomib, Cyclophosphamide and Dexamethasone)
II Left Ventricular Hypertrophy (presumed cocaine related) and pathological acetabular fracture due to myelomatous deposit.

The Record of Inquest recorded:

Box 3: A high globulin was identified in a blood test when Mr Edward Hearn attended A&E on 12th August 2018 with another illness. It was not followed up or repeated, but in retrospect was the first sign of multiple myeloma, which was diagnosed when he presented with systemic symptoms on 28th December, after three months of back and leg pains. He began chemotherapy and was discharged on 18th January without a safe care plan for minimizing the risk of fall and was readmitted on 29th January 2018 with a fracture, which immobilized him as he received chemotherapy. On 3rd February he suffered a sudden cardiac arrest, likely to have been contributed to by sepsis, bronchopneumonia and therapeutic chemotherapy medication. He died in hospital on 5th February 2018.

Box 4: Death was from a combination of natural disease and unintended consequences of necessary medical treatment. It was contributed to by a failure to make a safe care plan on discharge during the course of his chemotherapy.

1. The finding of a high globulin by a laboratory from a blood test in A&E was not followed up by either the laboratory or A&E department. It was not in College guidelines of tests which required urgent notification. It was indicative of a fatal disease, which was not diagnosed for approximately another 4 months. I accept the professional opinion of the haematologist that this was a system failure, which is not acknowledged by the Trust. The laboratory suggested an additional action to have an automated comment but that would still not deal with the problem of reports returning to physicians in secondary care. Evidence was heard that there is inconsistency in laboratory repeating and alerting of clinicians even between hospitals in the jurisdiction, and insufficient evidence of a safe system within the Trust.

2. The expert pharmaceutical physician gave a recommendation that the need for cardiac monitoring was made more definitive in the drug prescribing information for Carfilzomib (and possibly others), which was prescribed in the Cardamon Trial.