Joan Hanratty · Prevention of Future Deaths report

On 7th February 2018, I opened an inquest into the death of Joan Hanratty who was aged 75 years when she died at Tameside General Hospital, Ashton-under-Lyne on 28th January 2018. The investigation concluded at the end of the inquest which I heard on 30th April 2018.

The conclusion of the inquest was that Mrs Hanratty died as a consequence of septic shock due to pneumonia and Chronic Obstructive Pulmonary Disease against a background of multiple complex medical problems. At the end of the inquest, I recorded a conclusion of Natural Causes.

Mrs Hanratty had a complex medical history, which included heart failure, ischaemic heart disease, atrial fibrillation, hypertension and moderate to severe Chronic Obstructive Pulmonary Disease.

On 23rd January 2018, Mrs Hanratty contacted Denton Medical Practice and requested a prescription for antibiotics and steroids having developed a chest infection. As Mrs Hanratty was subject to regular review for her Chronic Obstructive Pulmonary Disease, a prescription for Amoxicillin and Prednisolone was issued automatically in accordance with relevant best-practice guidelines.

On 28th January 2018, Mrs Hanratty was brought into hospital by ambulance, having collapsed and suffered a cardiac arrest. Despite attempts to resuscitate her, she sadly died in hospital later that day.

It was confirmed in the course of evidence given at the inquest that under certain circumstances, patients who have been diagnosed with, and are subject to regular review as a result of, Chronic Obstructive Pulmonary Disease are issued with prescriptions for antibiotics and steroids upon request and without requirement for a telephone or in-person consultation with a doctor.

Whilst it is recognised that this practice accords with relevant clinical guidelines, it is a matter of concern that the system currently operated by the practice does not currently include explicit advice to patients that, in the event a significant improvement in condition is not experienced within a specified period of time of beginning antibiotic and steroid therapy, medical advice should be sought.