Violet Elizabeth Howard · Prevention of Future Deaths report

On 23 May 2022 an investigation into the death of Violet Elizabeth Howard was commenced. The investigation concluded at the end of the inquest on 2 September 2022. I recorded a conclusion of Natural Causes. The medical cause of death was recorded as 1a) Sepsis 1b) Hepatic abscess 2) Extensive eczematised psoriasis, Psoriasis with arthropathy and Type 1 Diabetes Mellitus

Ms Howard was admitted to Fairfield General Hospital on 13 March 2022 and diagnosed with sepsis caused by a hepatic abscess. She was transferred to the Royal Oldham Hospital (ROH) and underwent two procedures to drain the abscess. The abscess recurred and was not amenable to surgery because of its size and location. During the admission, Ms Howard developed a skin rash which required specialist dermatology input. From 22 April 2022, attempts were made by the treating team at the ROH to obtain dermatology input into Ms Howard’s care. This involved enquiries with Manchester Royal Infirmary, Whington Hospital and Salford Royal Hospital (SRH). The outcome of those enquiries was that even though Ms Howard was an inpatient at the ROH, a referral to the dermatology service covering ROH had to be made through her GP. The referral from Ms Howard’s GP was made and subsequently rejected on the basis that her postcode fell outside of the dermatology service's catchment area.

By 27 April 2022, Ms Howard’s skin condition was considered a dermatological emergency and as such she met the criteria for input from the dermatology team at SRH. I heard that the SRH dermatology clinic does not offer a service on 28 April and an appointment was made for Ms Howard to attend SRH on 29 April. Ms Howard was not able to attend this appointment as her condition deteriorated further on 28 April. A Consultant Dermatologist from SRH attended on Ms Howard at ROH on 1 May 2022 and diagnosed extensive eczematised psoriasis. This condition had impacted on Ms Howard’s fluid balance, renal function and general reserves and is a contributory factor in her death. Whilst the evidence did not meet the required standard to show that earlier dermatology input would have averted Ms Howard’s death, it would have mitigated the distress, discomfort and pain she experienced towards the end of her life.

(1) There is a gap in the commissioning arrangements for dermatology services covering in-patients at the Royal Oldham Hospital. Those arrangements do not cover in-patients who are from outside of the Oldham area unless and until they become ‘emergency dermatological cases’ and meet the criteria for input from dermatology at Salford Royal Hospital.