Shahida Begum · Prevention of Future Deaths report

On 26/11/2018 I commenced an investigation into the death of Shahida Begum. The investigation concluded at the end of the inquest 13th June 2019. The conclusion of the inquest was a narrative conclusion:
Mrs Begum presented with signs and symptoms that should have triggered further clinical observation and investigation on the 9 July 2018. She was diagnosed with muscle sprain and no further investigation was undertaken at that time. She then presented to hospital on the 10 July 2018 with signs of obvious sepsis. Despite treatment at this time, she passed away from the effects of an invasive Group A streptococcal infection. Had she received further observation and investigation on the 9 July 2018, it is likely that her death would have been avoided.

Mrs Begum became unwell on the evening of the 3 July 2018. She was unable to obtain an appointment with her registered GP and visited an out of hours GP on 6 July 2018. This GP diagnosed a urinary tract and throat infection and commenced treatment with trimethoprim and ibuprofen. Mrs Begum continued to deteriorate and on the 9 July 2018 she attended A&E. She was streamed by a doctor who directed her to the GP co-operative. The clinical streaming took place before her vital observations were taken. The streaming doctor later became aware of the observations, but did not change his decision to direct her to the GP. Her observations in A&E at that time should have triggered referral to A&E, where further observation and investigation should have been carried out. Instead, she was assessed by a GP who diagnosed muscular sprain and prescribed pain-killing medication. This GP should have recognised the need for further monitoring and review and should have directed her to A&E. On the 10 July 2018 she collapsed in her GP surgery and was taken as an emergency to hospital. She was found to be in obvious sepsis and despite treatment at this time, she passed away from an invasive group A streptococcal infection. She passed away in Newham University Hospital on the 10 July 2018.

The current system in place at Newham University Hospital is that a clinical streamer will make a decision about the destination of the patient (GP clinic; urgent treatment centre or A&E), before clinical observations are taken by the triage nurse. The decision is based upon an “eyeballing” check of the patient and a brief history from the patient. It was considered by myself, (as Coroner), by an independent emergency medicine expert and a senior doctor from Newham University Hospital that a safer system would be for the streamer to have the clinical observations available to them before they see the patient.