Daphne Penn
PFD Report
Historic (No Identified Response)
Ref: 2018-0206
Community health care and emergency services related deaths
Hospital Death (Clinical Procedures and medical management) related deaths
No published response · Over 2 years old
Response Status
Responses
0 of 2
56-Day Deadline
9 Oct 2018
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
Coroners Concerns
The inquest heard that; as well as the significant benefits that long term steroids can clearly bring to some conditions, there are also well recognised and significant potential risks including side effects such as () gastro intestinal bleeding; (ii) suppression of normal steroid production necessitating, when prescribed doses have to be reduced medically , slow and gradual dose reduction and the avoidance of sudden drops in the dose of steroids given; and (iii) , because of the long term suppression by prescribed long term steroids of the glands producing steroids in patients naturally, the need for prescribed doses to be increased where there is intercurrent illness, known as the 'Sick Day Rules' . The inquest also heard that a more rapid steroid reduction rate than that suggested by the original consultant was initiated, although the clinical reasons for this were given by the second consultant in respect of the need to balance benefits against the risk of further_gastro-intestinal_bleeding_here;_that_there_was a delay transmitting_to_relevant_ rapid and medical staff concerns about her condition expressed to healthcare staff by Mrs Penn's very supportive family, who clearly understood the issues related to steroids well; and that there was also an inadvertent additional decrease in the steroid dose prescribed following a prescribing error by a general medical practitioner who misread the intended steroid dose when rewriting the drug chart:
Action Should Be Taken
There was a significant medical history and multiple factors likely to have been involved in the tragic death of Mrs Daphne Penn but the inadvertently rapid reduction in the dose of prescribed steroids, on the balance of probabilities, is likely to have contributed to the death: In view of this, and the other factors noted, would wish to draw attention to:
1) The need to up notes in significant andlor long term conditions where the patient might be at risk if those conditions are not given adequate consideration.
2) The importance of recording and transmitting family concerns to all relevant clinical staff
3) Consider a safer system of prescribing, for example electronic, to reduce the risk of transcription and prescribing errors and also to ensure that all prescribing entries are clear and legible, and
4) To ensure that staff are aware of the 'Sick Rules' in respect of long term steroid use
1) The need to up notes in significant andlor long term conditions where the patient might be at risk if those conditions are not given adequate consideration.
2) The importance of recording and transmitting family concerns to all relevant clinical staff
3) Consider a safer system of prescribing, for example electronic, to reduce the risk of transcription and prescribing errors and also to ensure that all prescribing entries are clear and legible, and
4) To ensure that staff are aware of the 'Sick Rules' in respect of long term steroid use
Report Sections
Investigation and Inquest
At the conclusion of the inquest into the very sad death of DAPHNE JOAN PENN, recorded a narrative conclusion that 'Mrs Penn died from pneumonia occurring against a background of pre-existing significant natural disease and possibly due to aspiration in the final deterioration. Her last illness leading to her hospital admission was likely to have been multifactorial and contributed to, at least in part, by an inadvertently reduction in the dose of her long term steroid therapy' The cause of death was found to be: Ia Pneumonia
Circumstances of the Death
Mrs Daphne Penn had been transferred from West Suffolk Hospital to Newmarket Community Hospital for rehabilitation sadly died following her subsequent readmission to West Suffolk Hospital, her condition having deteriorated at Newmarket Community Hospital: She suffered from various pre-existing significant natural disease processes for which she took medication, including long term steroids, and there were problems associated with the provision of these steroids while she was patient at Newmarket Community Hospital.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.