JOAN DOROTHY RICHARDSON · Prevention of Future Deaths report

On 26th November 2013 I commenced an investigation into the death of JOAN DOROTHY RICHARDSON who was then aged 33. The investigation concluded at the end of the inquest on 28th May 2014. The conclusion of the inquest was Natural Causes, the cause of death being:-
1(a) Streptococcal Toxic Shock Syndrome

(1) Joan Dorothy Richardson lived with her partner, ████████ and her 14 year old son at ████████
(2) Ms Richardson became unwell with shivering, rapid onset of significant swelling of the whole of her right arm with bruising and discolouration of her skin. She also had swelling to her left hand.
(3) Ms Richardson was taken by her partner to her GP’s surgery, Fountain Medical Centre, during the early afternoon of 21st November 2013 to be told that the surgery was closed for a staff training session and that no Doctors were available.
(4) An appointment was made for the following day, 22nd November 2013 and when Ms Richardson was seen by a Doctor, the Doctor was sufficiently concerned and suspected a serious infective process and advised that she should have been taken to hospital immediately. An ambulance was offered, but Ms Richardson’s partner felt that he could take her to hospital more quickly in his car.
(5) Shortly after entering the Emergency Department at The General Infirmary at Leeds and whilst in the waiting area Ms Richardson had a cardiac arrest and despite all efforts her resuscitation was unsuccessful and her death was confirmed at 15:31 hours on 22nd November 2013, the working diagnosis being a pulmonary embolus itself or a serious condition.
(6) A Coroner’s post mortem examination showed the cause of death to be streptococcal toxic shock syndrome, stated to be a rare condition.
(7) It was the opinion of those who gave evidence at the Inquest that if Ms Richardson had entered hospital the previous day and had reached relevant treatment, the outcome may have been different.
(8) Delay may have been a contributory factor.

[BRIEF SUMMARY OF MATTERS OF CONCERN]
(1) It is correct and appropriate for GP practices to have dedicated time for staff training.
(2) This should be advertised well in advance by notices in the waiting area and in the entrances to the surgery with clear and specific instructions so that patients can seek emergency treatment elsewhere.
(3) On the occasions where there is a genuine emergency as there clearly was here, a Doctor should be available to deal with such an emergency notwithstanding that the surgery is closed for routine work, particularly when the training session is within normal surgery hours.
(4) This is an obvious issue for the Fountain Medical Centre but should also be addressed by all GP practitioners, hence the Leeds West Clinical Commissioning Group being incorporated within this Report to ensure that all GP practices adopt the same system. In my view it would be correct and appropriate for this issue to be addressed nationally.
(5) No criticism is made that a precise diagnosis was not made. Nevertheless had Ms Richardson been seen on the 21st November 2013 it would have been obvious that she was extremely unwell and that her presentation was urgent and that time was of the essence and that she should have been referred to hospital immediately.
(6) The delay of almost 24 hours has been a contributory factor.