Joan Hanratty
PFD Report
Historic (No Identified Response)
Ref: 2018-0141
Coroner's Concerns (AI summary)
The system for providing antibiotics and steroids to COPD patients on request lacks explicit advice for them to seek medical attention if their condition does not improve within a specified period.
View full coroner's concerns
aged The day:
It was confirmed in the course of evidence given at the inquest that under certain circumstances, patients who have been diagnosed with, and are subject to regular review as a result of, Chronic Obstructive Pulmonary Disease are issued with prescriptions for antibiotics and steroids upon request and without requirement for a telephone or in-person consultation with a doctor. Whilst it is recognised that this practice accords with relevant clinical guidelines, it is a matter of concern that the system currently operated by the practice does not currently include explicit advice to patients that; in the event a significant improvement in condition is not experienced within a specified period of time of beginning antibiotic and steroid therapy, medical advice should be sought:
It was confirmed in the course of evidence given at the inquest that under certain circumstances, patients who have been diagnosed with, and are subject to regular review as a result of, Chronic Obstructive Pulmonary Disease are issued with prescriptions for antibiotics and steroids upon request and without requirement for a telephone or in-person consultation with a doctor. Whilst it is recognised that this practice accords with relevant clinical guidelines, it is a matter of concern that the system currently operated by the practice does not currently include explicit advice to patients that; in the event a significant improvement in condition is not experienced within a specified period of time of beginning antibiotic and steroid therapy, medical advice should be sought:
Sent To
- Denton Medical Centre
Response Status
Linked responses
0 of 1
56-Day Deadline
4 Jul 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
Investigation and Inquest
On 7th February 2018, | opened an inquest into the death of Joan Hanratty who was 75 years when she died at Tameside General Hospital, Ashton under-Lyne on 28'h January 2018_ The investigation concluded at the end of the inquest which heard on 30"h April 2018_ conclusion of the inquest was that Mrs Hanratty died a5 a consequence of septic shock due to pneumonia and Chronic Obstructive Pulmonary Disease against a background of multiple complex medical problems: At the end of the inquest;, recorded a conclusion of Natural Causes
Circumstances of the Death
Mrs Hanratty had a complex medical history, which included heart failure, ischaemic heart disease , atrial fibrillation, hypertension and moderate to severe Chronic Obstructive Pulmonary Disease. On 23" January 2018,Mrs Hanratty contacted Denton Medical Practice and requested a prescription for antibiotics and steroids having developed a chest infection. As Mrs Hanratty was subject to regular review for her Chronic Obstructive Pulmonary Disease, a prescription for Amoxicillin and Prednisolone was issued automatically in accordance with relevant best-practice guidelines. On 28'h January 2018, Mrs Hanratty was brought into hospital by ambulance, having collapsed and suffered a cardiac arrest Despite attempts to resuscitate her, she sadly died in hospital later that
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe you and your organisation the power to take such action:
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.