Christine Margaret Cumbers · Prevention of Future Deaths report

On 10 May 2022 I commenced an investigation into the death of Christine Margaret Cumbers. The investigation concluded at the end of the inquest on 19 May 2023.

The conclusion of the inquest was a narrative conclusion:

Christine Margaret Cumbers suffered with Hyperthyroidism and was admitted to hospital with a skin rash eruption secondary to Carbimazole use, a rare but recognised complication of this necessary Hyperthyroidism first line medical treatment. She developed sepsis during her hospital admission which was belatedly diagnosed and treated due to lack of continuity of care caused by multiple ward moves. The belated diagnosis and treatment of sepsis more than minimally contributed to the death on 22 April 2022 at Colchester General Hospital, Essex.

Christine Margaret CUMBERS was born on 3 September 1948 and at the time of her death on 22 April 2022 she lived in Clacton-on-Sea, Essex.

Mrs Cumbers was known to have Hyperthyroidism, Hypertension, Osteoarthritis, Hypercholesterolaemia and a stable Angina.

On 29 March 2022, Mrs CUMBERS was admitted to Colchester Hospital, having presented with skin eruption following use of Carbimazole, prescribed for an overactive Thyroid, by her GP at above named Practice.

Mrs Cumbers suffered an allergic reaction to the prescribed Carbimazole, she stopped Carbimazole and reported it to the GP practice on 21 March.

She was seen by a GP on 22 March in person, on 24 March there was a failed home visit with no follow up call directly to Mrs Cumbers, on 25 March there was a consultation via telephone, on 28 March she spoke to reception and later a nurse over the telephone and on 29 March she was seen at home.

The GP Practice carried out an internal review of the incident, including the consultations conducted by the various GPs and other clinical staff and produced a “Significant Event Analysis” report. This report was admitted as evidence as part of the coronial investigation and identified that a clinician should have followed up on the failed encounter and the consultation on 28 March did not meet the required standards and the management of the care was found to be wrong, leading to a delay in administration of antibiotics and hospital admission. The evidence showed that this event did not cause or contributed to the death on the balance of probabilities.

However, the Practice confirmed in evidence that no actions have been taken to embed the learnings identified in the Significant Event Analysis report, to ensure the appropriate standards are upheld by the Practice’s clinical staff when carrying out consultations and providing treatment.

The Practice, despite identifying shortcomings in their practice, took no action to implement the learnings identified in the Significant Event Analysis report and, as at the date of the inquest, no details of plans or timescales for implementation were available.