Karen Lesley SUTTON · Prevention of Future Deaths report

On the 18th October 2012 an investigation into the death of Karen Lesley SUTTON date of birth 10 November 1959. The investigation concluded at the end of the inquest on 2nd September 2013. The conclusion of the inquest was Natural Causes.
The cause of death was
1a. Sepsis
1b. Streptococcus pneumoniae infection
1c. Common variable immunodeficiency and low grade non-Hodgkin Lymphoma and Splenectomy
2. Hepatic cirrhosis

Mrs Sutton had been diagnosed with primary antibody deficiency disorder in September 2001 and from this time was under the care of the Immunology teamand her care was led by ████████ at Leicester Royal Infirmary. As part of her ongoing treatment she underwent splenectomy during 2005, and thereafter required lifelong anti-biotic therapy most latterly in the form of daily azithromycin.

She required admissions during August and September 2012 for symptoms of infection, and was treated by the medical teams at Glenfield Hospital. Her admission medications including Antibiotic prophylactic cover were discontinued, and not restarted on discharge.

Mrs Sutton was readmitted on 11th October 2012 as an emergency and was found to be suffering from a severe sepsis, and despite timely interventions, went into cardiac arrest and died that evening.

(1) Not withstanding her 12 year history of regular Immunology follow-up, the team were not notified of her admission to hospital , on either occasion during August and September 2012, and thus given the opportunity to have input into her care and her discharge.
(2) Mrs Sutton was discharged home without prophylactic antibiotic medication
(3) Mrs Sutton was left to arrange her next out patient appointment and it was fortuitous that ████████ was able to see her after the day of discharge, 4th October 2012.
(4) ████████ was unaware of any Trust policy to share admissions between departments. He acknowledged this as a Learning point and although he has personally instigated a practice to encourage patients and /or their relatives to let his department know of any admissions, this is neither robust or in some circumstances practical and cannot be relied upon as a means of communication Trust-wide.