Theresa Mary Thompson · Prevention of Future Deaths report

Theresa Mary Thompson died on the 9th October 2016 at the Royal Cornwall Hospital, Treliske, Truro while on holiday in Cornwall. An inquest was opened on the 14th October and concluded at Truro Municipal Buildings, Truro on 29th March 2017 with a conclusion of Natural Causes

Theresa Thompson underwent a Splenectomy when she was child in 1958 because of familial Acholuric Jaundice. Following the procedure she was advised on the need for indefinite prophylaxis with antibiotics to redress the risk of infection due to the reduction in efficiency of her immune system following the removal of the spleen. Mrs Thompson at some point declined antibiotics. In March 2013 she underwent ventriculo-peritoneal shunt. She developed sigmoid perforation and peritonitis in June 2013 and the infected ventriculo-peritoneal shunt was removed in Kings College Hospital, London. A new ventriculo-peritoneal shunt was re-inserted at Kings College Hospital, London on 8th August 2016 without prophylaxis antibiotics. She went on holiday to Cornwall and whilst on holiday she was admitted to the Royal Cornwall Hospital, Treliske, Truro on 8th October 2016 with sepsis from a Streptococcus pneumonia infection from which she died on 9th October 2016.

A post mortem was carried out and the cause of death was established as 1a Multi-organ failure 1b Sepsis 1c Streptococcus Pneumonia II Ventriculo-Peritoneal Shunt for Normal Pressure Hydrocephalus, Previous bowel Perforation in 2013 with peritonitis, Splenectomy as child.

At the inquest, the pathologist advised that Streptococcus pneumonia infections were typical for patients having undergone splenectomy. The spleen was an important immune defence organ for this type of bacteria. Usually patients were given a vaccination to prevent this type of disease and life-time antibiotic prophylaxis. Both the Pathologist and Treating clinician at the time of death, expressed concerns to the inquest that Mrs Thompson was not on prophylaxis antibiotics and that she had no antibiotic prophylaxis cover for her recent procedure especially as the Streptococcus infection was Serum type 6C for which there was no currently available pneumococcal vaccines (Reference report from Public Health England, Colindale, The Respiratory and Vaccine Preventable Bacteria Reference Unit (RVPBRU)).

The GP gave evidence that Mrs Thompson had been advised about inoculation and taking life-long antibiotic prophylaxis but at some point had declined (although there were no written records to support his evidence in her medical note). There was no evidence that she was advised or prescribed antibiotics prior to or after her Ventriculo-Peritoneal Shunt procedure in August 2016 at Kings College Hospital.

The family acknowledged that a number of the family had had a splenectomy due to familial Acholuric Jaundice but they were unsure that the family members appreciated the necessity for inoculation or prophylaxis antibiotics. They were concerned that there were mixed messages being given out by the Health Agencies about the use of antibiotics and the need to not overuse antibiotics and this had led to them not being inoculated or accepting life time prophylaxis antibiotics or the necessity of cover during medical procedures (if they had been advised at all).