Gabriele Kreichgauer · Prevention of Future Deaths report

On 1 February 2018 I commenced an investigation into the death of Gabriele Kreichgauer, age 61. The investigation concluded at the end of the inquest on 15 February 2019. The conclusion of the inquest was that Ms Kreichgauer died of sepsis following an infected cat bite of her hand.

Ms Kreichgauer attended Newham General Hospital A&E on 21 January 2018 with an infected cat bite in her hand. It was intended that she should receive antibiotics but these were not given to her and she was discharged from the department. She went on to develop sepsis and died at Queen Elizabeth Hospital on 23 January 2018.

(1) Ms Kreichgauer left the department without being given antibiotics. The reason for this appears to have been that no-one did a final check on what treatment was considered and whether this had been given to her.

(2) The junior doctor who saw Ms Kreichgauer used an internet resource called “Uptodate”. The evidence was that the Trust supplies the subscription for this. He searched under the phrase “cat bite” and was directed to a diagnosis of cat scratch fever. On this basis he planned to prescribe azithromycin. In fact, the correct diagnosis was that Ms Kreichgauer had an infected cat bite; the infective organism for this is different to the organism causing cat scratch fever; and the appropriate treatment is different. Even if she had been given antibiotics it is therefore likely that these would not have been effective.

At the inquest the clinicians accepted that it would be helpful for there to be a warning on Uptodate pointing out the need to consider the possibility of infected cat bite (and the important difference between this and cat scratch fever) when searching under either term (“cat bite” or “cat scratch”). It was accepted that the Trust should be in a position to communicate with Uptodate to point out this concern.

(3) There does not appear to be a feedback mechanism within Uptodate to allow clinicians to notify it of any concerns. Again, as a subscriber to Uptodate, this is a matter that the Trust is likely to be in a position to take up with them.