Investigation and inquest
On 12th June 2013 I commenced an investigation into the death of Refat Hussain aged 25 years. The investigation concluded at the end of the inquest on 17th December 2013. The conclusion of the inquest was Medical Cause of death:
1a Multi-organ failure.
b In hospital cardiac arrest
c Pulmonary Tuberculosis and pneumonia
II Rubenstein Taybi Syndrome.
Conclusion of the Coroner as to the Death:
On 15/4/2013 Ms Refat Hussain was admitted to St Georges Hospital. She was initially diagnosed with bilateral community acquired pneumonia, was treated and improved a little. However, she developed haemoptysis on 21/4/2013 and suffered a cardiac arrest on 22/4/2013. She was confirmed the same day as suffering form pulmonary TB. Despite all active treatment she deteriorated and died on ITU on 11/5/2013. She had developed active signs of TB in February 2013. If she had been diagnosed and treated appropriately at that time then on the balance of probabilities the death would have been averted.
Circumstances of the death
Ms Hussain was part of an extended family most of whom developed either open TB or latent TB at the material time. Refat herself had been diagnosed with latent TB but had not received treatment for this. In the early of February 2013, she had developed symptoms consistent with active TB, which for various reasons went unrecognised.
On 30th March 2013, she was visited at home by a Harmoni████████ who based upon the history given at the time and the examination of Ms Hussain, diagnosed a chest infection and prescribed antibiotics.
████████had no access to Ms Hussain’s usual GP records, nor that of her family members which may have assisted him to make the diagnosis of TB and arrange appropriate treatment. It is possible that had ████████ had such background information this death may have been averted.
Based upon the information available to him, ████████ diagnosis and treatment was reasonable and appropriate. This situation was further complicated as Ms Hussain was unable to give a clear history herself due to her Rubenstein Taybi syndrome.
Coroner’s concerns
(1) The lack of access to the patients GP medical records reduces the ability of out of hours GPs working for Harmoni to make accurate diagnoses.