UK Inquiry Tracker

Lindsey Tyrrell

PFD Report Historic (No Identified Response) Ref: 2018-0208

Date of Report 29 June 2018

Coroner Anthony Mazzag

Coroner Area Manchester (City)

Response Deadline est. 9 October 2018

Hospital Death (Clinical Procedures and medical management) related deaths

Judiciary.uk Report PDF

Coroner's Concerns (AI summary)

Routine testing for toxoplasmosis was not performed on stem cell transplant patients with infection signs, and local learning needs nationwide sharing.

View full coroner's concerns

heard evidence at the Inquest that toxoplasmosis IS carried by about 30% of the population, however prior to Mrs Tyrell's death testing for this Infection was not routinely carried out at the Christie Hospital on patients who had received an allogeneic stem cell transplant and who had subsequently presented with signs of Infection heard evidence that;, following Mrs Tyrell's death, testing for toxoplasmosis IS now undertaken at the Christie Hospital when stem cell transplant patients present In similar circumstances However; there was no evidence before me as to the practice of other specialist blood cancer care units or hospitals In similar circumstances It seems appropriate that the learning from this incident at a local level should be shared on a nationwide basis

Sent To

Department of Health and Social Care
NHS England

Response Status

Linked responses 0 of 2

56-Day Deadline 9 Oct 2018

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

Circumstances of the Death

In November 2014, Mrs Tyrell was diagnosed With B-cell Acute Lymphoblastic Leukaemia (B-ALL') She was commenced on intensive chemotherapy which she tolerated well She achieved complete remission of her disease and was moved to maintenance therapy In September 2015 Unfortunately, In December 2016, It was noted that her bloods were deteriorating and marrow Investigations revealed relapse of her B-ALL At that stage, the only prospect for long term survival was an allogenelc stem cell transplant Accordingly, on March 2017, Mrs Tyrell underwent an unrelated donor stem cell transplant She received appropriate Immunosuppressive treatment and was therefore at high risk of developing_an Infection over the next 12 months 24th

At the beginning of June 2017 , Mrs Tyrell presented at the Christie Hospital with headaches, fever and an intermittent rash She had clearly developed an infection by that point Investigations were carried out to Identify the nature of the Infection However _ no evidence of Infection was found on routine blood testing She was also routinely scanned for evidence of infection In her brain but nothing abnormal was noted Mrs Tyrell continued to deteriorate On 21st June a lumbar puncture test was performed but no infection was found In the cerebrospinal fluid ('CSF' Over the course of 27th June to 29th June, there was significant deterioration In Mrs Tyrell's condition and by 30th June, the prognosis was terminal She passed away on 3rd July 2017 Following her death, the Christie Hospital reanalysed the bloods taken during the course of Mrs Tyrell's last admission to hospital It was found that her blood samples from 5ih June 2017 onwards tested positive for toxoplasma The CFS from 21st June was also retested and found to be positive for toxoplasma

Action Should Be Taken

In my opinion action should be taken to prevent future deaths and belleve you and your organisation have the power to take such action