Graham Earl · Prevention of Future Deaths report

On 20th February 2019 I commenced an investigation into the death of Graham Earl. The investigation concluded on the 14th August 2019 and the conclusion was one of Narrative: Died from influenza exacerbated by the complications of prescribed medication, namely Amiodarone. The medical cause of death was 1a) Influenza Pneumonia on a background of Pulmonary Fibrosis caused by Amiodarone therapy; ii) Diabetes Mellitus (Type 2), Ischaemic Heart Disease, Atrial Fibrillation

Graham Earl had a history of Atrial Fibrillation. A Cardioversion on 2nd May 2018 successfully restored his heart rhythm. Amiodarone was prescribed to maintain his rhythm. On 2nd January 2019 he was diagnosed via a chest x-ray with Pulmonary Fibrosis, a known complication of Amiodarone therapy. He was not referred back to the cardiologist. Had he been referred back, the Amiodarone would have been stopped. He continued to deteriorate. On 14th February 2019 he was acutely unwell and was admitted to Stepping Hill Hospital. He was diagnosed with influenza. His Pulmonary Fibrosis exacerbated the impact of the influenza. He deteriorated and died at Stepping Hill Hospital on 16th February 2019.

1. The GPs involved did not understand or recognise the known link between the therapy and Pulmonary Fibrosis and did not seek guidance from the prescribing secondary care physician at an early stage. The evidence was that the advice would have been to stop prescribing immediately;

2. A GP amended the prescription subsequently without reference to the secondary care doctor despite the fact that this is not a medication started in primary care;

3. The indication was that GPs involved were not aware of what they should do if there were side effects from the medication in terms of escalation;

4. The drug is currently green on the CCG classification. In other CCG areas it is amber given the known side effects.