Margaret Wilson
PFD Report
Historic (No Identified Response)
Ref: 2019-0163
Coroner's Concerns (AI summary)
Failure to conduct a crucial blood test, as per national guidelines, masked Endocarditis, leading to a missed diagnosis and delayed treatment that would likely have resulted in a different outcome.
View full coroner's concerns
1. A blood test should have been done, in compliance with national guidelines, which would have confirmed Endocarditis. The absence of such test and the prescribing of antibiotics masked the disease.
2. Earlier diagnosis and treatment would more likely than not have resulted in a different outcome.
In addition it was later recognised that the finger symptoms were most likely due to Endocarditis.
2. Earlier diagnosis and treatment would more likely than not have resulted in a different outcome.
In addition it was later recognised that the finger symptoms were most likely due to Endocarditis.
Sent To
- MFT
Response Status
Linked responses
0 of 2
56-Day Deadline
23 Sep 2019
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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
I concluded the inquest into the death of Margaret Bernadette WILSON on 17 July 2018 and recorded that he/she died from:
1a Cardiac failure and arrest
1b Acute myocardial infarction and acute aortic valve endocarditis (with surgical intervention on July 18th 2017).
1a Cardiac failure and arrest
1b Acute myocardial infarction and acute aortic valve endocarditis (with surgical intervention on July 18th 2017).
Circumstances of the Death
Mrs Wilson was admitted to Trafford General Hospital Urgent Care centre on the 18th of June 2017 complaining of swelling and pain in her right arm and shoulder, she also had bruising and swelling of her index and middle finger for four days.
She was provisionally diagnosed with cellulitis and antibiotics were started. Of note, no blood tests were performed prior to commencing antibiotics.
On the 2nd of July 2017 the deceased complained of central crushing chest pain and was transferred to Manchester Royal infirmary. Endocarditis was then diagnosed however, despite treatment, the deceased failed to respond and died on 20th July 2017. I attach a copy of the record of inquest confirming the cause of death.
Evidence heard at the Inquest confirmed that a blood test ought to have been performed prior to the prescribing of antibiotics.
She was provisionally diagnosed with cellulitis and antibiotics were started. Of note, no blood tests were performed prior to commencing antibiotics.
On the 2nd of July 2017 the deceased complained of central crushing chest pain and was transferred to Manchester Royal infirmary. Endocarditis was then diagnosed however, despite treatment, the deceased failed to respond and died on 20th July 2017. I attach a copy of the record of inquest confirming the cause of death.
Evidence heard at the Inquest confirmed that a blood test ought to have been performed prior to the prescribing of antibiotics.
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Delayed Recognition of Deterioration
Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.