Rubana Pathan
PFD Report
Partially Responded
Ref: 2016-0113
1 of 2 responded · Over 2 years old
Response Status
Responses
1 of 2
56-Day Deadline
13 May 2016
Over 2 years old — no identified published response
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Coroner’s Concerns
Although Ms Pathan’s MENTOR breast implant was suspected as being the cause of her sepsis and was removed on the evening of Saturday, 7 November 2015, her surgeon told me at inquest that she still did not believe this to be the cause, because she found no pus or localised redness.
However, one of the treating microbiologists undertook a literature search after Ms Pathan’s death and discovered that the toxin found to be responsible for her illness can supress signs of local inflammation such as the production of pus.
Although this is a rare occurrence, it seems to me that the information could usefully be disseminated among those likely to be caring for patients who may be at risk of developing sepsis, both by the hospital and by the implant manufacturer.
However, one of the treating microbiologists undertook a literature search after Ms Pathan’s death and discovered that the toxin found to be responsible for her illness can supress signs of local inflammation such as the production of pus.
Although this is a rare occurrence, it seems to me that the information could usefully be disseminated among those likely to be caring for patients who may be at risk of developing sepsis, both by the hospital and by the implant manufacturer.
Responses
Response received
View full response
Dear Coroner Hassell,
Re: Prevention of Future Deaths notice in relation to Staphylococcal Toxic Shock Syndrome
Thank you for the email sent on 21st March, which contained a Prevention of Future Deaths notice in relation to the care of Mrs Rubana Pathan. As you know, Mrs Pathan sadly died on 21st November 2015 from Staphylococcus aureus Toxic Shock Syndrome following breast implant surgery. In the PFD, you requested that we disseminate information about this particular and rare manifestation among our clinicians who are responsible for caring for patients who are at risk of developing sepsis. I am writing to confirm the actions undertaken in response by Homerton University Hospital.
1. I requested that , the microbiologist who gave evidence at the inquest, perform an evidence and literature search on surgical site Staphylococcal Toxic Shock Syndrome, with particular reference to suppression of pus formation resulting in benign-looking wounds.
2. I have highlighted the need to have a high index of suspicion for sepsis associated with Staphylococcal Toxic Shock Syndrome, and shared detailed literature search, with all doctors in the Trust by email.
3. The case will be discussed in detail at a Hospital Grand Round, in order to ensure that the organisation learns as much as possible from this sad occurrence. The Grand Round was scheduled to take place on 26th April, but unfortunately had to be postponed due to the junior doctors’ industrial action which took place that day, so will take place on 28th June.
4. The Trust has directed particular focus on encouraging early recognition and treatment of patients with sepsis, as part of its Improving Quality programme. In Quarter 4 of 2015-16 we were extremely pleased that all patients admitted to Homerton with severe sepsis received antibiotics within one hour. In 2016/17, we are broadening the focus of this programme, seeking to improve the recognition, escalation and treatment of patients on our in-patient wards with potential sepsis.
Coroner Mary Hassell Senior Coroner Inner North London St Pancras Coroner’s Court Camley Street London, N1C 4PP
By email to Coroner’s office:
Incorporating hospital and community health services, teaching and research
- 2 - I do hope that this provides assurance that we have taken appropriate action in response to the PFD notice. Please do not hesitate to contact me if you require any further information.
Re: Prevention of Future Deaths notice in relation to Staphylococcal Toxic Shock Syndrome
Thank you for the email sent on 21st March, which contained a Prevention of Future Deaths notice in relation to the care of Mrs Rubana Pathan. As you know, Mrs Pathan sadly died on 21st November 2015 from Staphylococcus aureus Toxic Shock Syndrome following breast implant surgery. In the PFD, you requested that we disseminate information about this particular and rare manifestation among our clinicians who are responsible for caring for patients who are at risk of developing sepsis. I am writing to confirm the actions undertaken in response by Homerton University Hospital.
1. I requested that , the microbiologist who gave evidence at the inquest, perform an evidence and literature search on surgical site Staphylococcal Toxic Shock Syndrome, with particular reference to suppression of pus formation resulting in benign-looking wounds.
2. I have highlighted the need to have a high index of suspicion for sepsis associated with Staphylococcal Toxic Shock Syndrome, and shared detailed literature search, with all doctors in the Trust by email.
3. The case will be discussed in detail at a Hospital Grand Round, in order to ensure that the organisation learns as much as possible from this sad occurrence. The Grand Round was scheduled to take place on 26th April, but unfortunately had to be postponed due to the junior doctors’ industrial action which took place that day, so will take place on 28th June.
4. The Trust has directed particular focus on encouraging early recognition and treatment of patients with sepsis, as part of its Improving Quality programme. In Quarter 4 of 2015-16 we were extremely pleased that all patients admitted to Homerton with severe sepsis received antibiotics within one hour. In 2016/17, we are broadening the focus of this programme, seeking to improve the recognition, escalation and treatment of patients on our in-patient wards with potential sepsis.
Coroner Mary Hassell Senior Coroner Inner North London St Pancras Coroner’s Court Camley Street London, N1C 4PP
By email to Coroner’s office:
Incorporating hospital and community health services, teaching and research
- 2 - I do hope that this provides assurance that we have taken appropriate action in response to the PFD notice. Please do not hesitate to contact me if you require any further information.
Report Sections
Investigation and Inquest
On 25 November 2015, one of my assistant coroners, Richard Britain, commenced an investigation into the death of Rubana Pathan, aged 40 years. The investigation concluded at the end of the inquest earlier today. I made a determination as follows. Rubana Pathan died as a consequence of a rare but recognised complication of medical treatment, being a staphylococcal aureus infection of her breast implant wound. (Breast reconstruction following a mastectomy undertaken to treat breast cancer.)
Circumstances of the Death
Ms Pathan was admitted to Homerton University Hospital on Thursday, 5 November 2015 and was immediately recognised to be potentially very unwell. Her breast reconstruction wound later grew staphylococcus aureus, she was found to be positive for the TSST-1 gene, and was diagnosed with toxic shock syndrome.
I recorded a medical cause of death of:
1a toxic shock syndrome 1b staphylococcus aureus infection 1c infected breast implant wound
I recorded a medical cause of death of:
1a toxic shock syndrome 1b staphylococcus aureus infection 1c infected breast implant wound
Copies Sent To
Professor Dame Sally Davies, Chief Medical Officer for England
Medicines and Healthcare Products Regulatory Agency
surgeon, Homerton University Hospital
, microbiologist, Homerton University Hospital
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.