Sufia Begum
PFD Report
All Responded
All 2 responses received
· Deadline: 14 Nov 2018
Coroner's Concerns (AI summary)
Many doctors are unaware of the BNF mobile app, a crucial tool for identifying potential drug interactions, risking preventable deaths from unknown medication interactions.
View full coroner's concerns
During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. 1. I heard evidence at the inquest that the most useful tool to identify potential drug interactions was the BNF mobile device APP. The author of the RCA confirmed that not all doctors were aware of the APP. An alert to all NHS Trusts and GPs would provide this valuable information which may prevent a future death from an unknown drug interaction.
Responses
Sent To
- NHS England
Response Status
Linked responses
2 of 2
56-Day Deadline
14 Nov 2018
All responses received
About PFD responses
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 26/04/2018 I commenced an investigation into the death of Sufia Begum. The investigation concluded at the end of an inquest on 20th August 2018. The conclusion of the inquest was:‐ Died from an unrecognised adverse drug interaction.
Circumstances of the Death
The deceased was admitted to the Queen Elizabeth Hospital in Birmingham on 14/04/18 suffering from vomiting, confusion and generalised weakness. She had previously been treated at City Hospital for exacerbation of asthma from 07/04/18 – 09/04/18 and had been prescribed clarithromycin. Tests at the Queen Elizabeth Hospital confirmed she was suffering from an accumulation of verapamil (a calcium channel blocker drug she was already taking) caused by the prescription of clarithromycin which inhibits the enzyme which breaks down verapamil. It had not been recognised at the time that verapamil interacts with clarithromycin. Despite treatment she died on 24/04/18.
Based on information from the Deceased’s treating clinicians the medical cause of death was determined to be: MULTIORGAN FAILURE CALCIUM CHANNEL BLOCKER TOXICITY
ATRIAL FIBRILLATION
Based on information from the Deceased’s treating clinicians the medical cause of death was determined to be: MULTIORGAN FAILURE CALCIUM CHANNEL BLOCKER TOXICITY
ATRIAL FIBRILLATION
Copies Sent To
I am also under a duty to send the Chief Coroner a copy of your response
Signature
Louise Hunt Senior Coroner Birmingham and Solihull
Similar PFD Reports
Reports sharing organisations, categories, or themes
Related Inquiry Recommendations
Public inquiry recommendations addressing similar themes
GMMH local structured risk assessment responsibility
Southport Inquiry
Poor health and social care integration
Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.