Maureen Johnson
PFD Report
All Responded
Ref: 2021-0298
All 1 response received
· Deadline: 2 Nov 2021
Coroner's Concerns (AI summary)
A lack of authoritative national guidance for assessing gastroenteritis, dehydration, and the need for face-to-face reviews in patients over 70 poses a risk.
View full coroner's concerns
Given their physiological susceptibility to dehydration and its effects, it is a matter of concern that authoritative guidance does not currently exist as to the assessment of diarrhoea and vomiting suspected to be caused by gastroenteritis in the over 70s, as has previously been published in respect of children and infants younger than 5.
Such guidance might usefully provide a comprehensive overview of symptoms and signs of clinical dehydration in the over 70s, and give clinicians advice as to the circumstances in which a face-to-face assessment is recommended.
Such guidance might usefully provide a comprehensive overview of symptoms and signs of clinical dehydration in the over 70s, and give clinicians advice as to the circumstances in which a face-to-face assessment is recommended.
Responses
Noted
NICE states they have a Clinical Knowledge Summary on gastroenteritis, which they believe gives appropriate advice, and that no action is required of them. (AI summary)
NICE states they have a Clinical Knowledge Summary on gastroenteritis, which they believe gives appropriate advice, and that no action is required of them. (AI summary)
View full response
Dear Mr Morris,
I write in response to your regulation 28 report of 7 September 2021 regarding the death of Maureen Johnson. I would like to express my sincere condolences to her family.
In your report you state that ‘authoritative guidance does not currently exist as to the assessment of diarrhoea and vomiting suspected to be caused by gastroenteritis in the over 70s, as has previously been published in respect of children and infants younger than 5.’
While it is correct that we have not published a clinical guideline on gastroenteritis in adults, or children over the age of 5, there is a Clinical Knowledge Summary on gastroenteritis which we believe gives appropriate advice on the assessment of people who are suspected to have gastroenteritis, including questions that healthcare professionals should ask, the need to examine the person, the risk of dehydration, and symptoms to be aware of.
While they do not constitute formal NICE guidance, we commission Clarity Informatics to develop the summaries, and make them available as a source of information for health professionals.
As such, we do not believe that any action is required of NICE.
I write in response to your regulation 28 report of 7 September 2021 regarding the death of Maureen Johnson. I would like to express my sincere condolences to her family.
In your report you state that ‘authoritative guidance does not currently exist as to the assessment of diarrhoea and vomiting suspected to be caused by gastroenteritis in the over 70s, as has previously been published in respect of children and infants younger than 5.’
While it is correct that we have not published a clinical guideline on gastroenteritis in adults, or children over the age of 5, there is a Clinical Knowledge Summary on gastroenteritis which we believe gives appropriate advice on the assessment of people who are suspected to have gastroenteritis, including questions that healthcare professionals should ask, the need to examine the person, the risk of dehydration, and symptoms to be aware of.
While they do not constitute formal NICE guidance, we commission Clarity Informatics to develop the summaries, and make them available as a source of information for health professionals.
As such, we do not believe that any action is required of NICE.
Sent To
- National Institute for Health and Care Excellence
Response Status
Linked responses
1 of 1
56-Day Deadline
2 Nov 2021
All responses received
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Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On 26th March 2021, Christopher Murray, Assistant Coroner, opened an inquest into the death of Maureen Johnson who died on 13th March 2021 at Stepping Hill Hospital, Stockport, aged 85 years. The investigation concluded at the end of the inquest which I heard on 1st September 2021. A doctor treating Mrs Johnson confirmed that she had died as a result of:
1.a) Acute Renal Failure; due to
1.b) Dehydration;
1.c) Gastroenteritis II Hypertension. By way of conclusion, I recorded that Mrs Johnson died as a consequence of Natural Causes.
1.a) Acute Renal Failure; due to
1.b) Dehydration;
1.c) Gastroenteritis II Hypertension. By way of conclusion, I recorded that Mrs Johnson died as a consequence of Natural Causes.
Circumstances of the Death
Mrs Johnson was ordinarily a fit and active person who lived independently in her own home. Towards the end of February 2021, Mrs Johnson became unwell with diarrhoea, vomiting and abdominal pain. After around a week, Mrs Johnson’s symptoms had resolved, however returned again a number of days later. Mrs Johnson sought medical advice. In the two days prior to her death, two separate General Practitioners held telephone consultations with Mrs Johnson and formed the impression (albeit without examining her) that she had been suffering from a stomach bug which was resolving.
On 13th March 2021, Mrs Johnson’s son (who had been in regular contact with his mother throughout) spoke to her on the telephone and was concerned she sounded short of breath. On attending her home, Mr Johnson found his mother to be seriously ill.
An ambulance was called, and Mrs Johnson was taken to Stepping Hill Hospital where it was quickly recognised she had developed metabolic acidosis and was gravely ill. Despite attempts to provide emergency treatment, Mrs Johnson died later that afternoon.
On 13th March 2021, Mrs Johnson’s son (who had been in regular contact with his mother throughout) spoke to her on the telephone and was concerned she sounded short of breath. On attending her home, Mr Johnson found his mother to be seriously ill.
An ambulance was called, and Mrs Johnson was taken to Stepping Hill Hospital where it was quickly recognised she had developed metabolic acidosis and was gravely ill. Despite attempts to provide emergency treatment, Mrs Johnson died later that afternoon.
Copies Sent To
to the Inquest
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.