In June 2015 I commenced an investigation into the death of Mrs Kay Morrison. The investigation concluded following an inquest in December 2017 where the narrative conclusion set out that: Mrs Morrison underwent necessary surgery on the 11th June 2015 at the Royal  Hallamshire Hospital, Sheffield.  No proper antibiotic history was obtained and Mrs  Morrison developed a severe bacterial infection, and subsequently a severe fungal  infection, following the (correctly carried out) procedure.  Mrs Morrison died of sepsis  on the 21st June 2015.  On the balance of probabilities, the death occurring when it did was contributed to by  the lack of a proper antibiotic history.

Mrs Morrison lived in Cumbria but had been referred to the tertiary centre in Sheffield for specialist surgical care. Unfortunately, her historical records not being local, a full and proper antibiotic history was not obtained. It was clear that Mrs Morrison had been subject of many infections and been repeatedly prescribed antibiotics. It could have been recognised that she had previously had an ESBL infection that was not susceptible to certain antibiotics. An independent microbiologist gave evidence that there was a history of UTI’s treated with antibiotics both at various hospitals and in the community. There were two positive tests for E. coli in 2014 (June and October). There was some correspondence in the records about multiple antibiotic treatments.

This lack of a proper history led to Mrs Morrison being prescribed antibiotics both by way of prophylaxis and treatment which were not going to serve their purpose. The court found this to be a serious omission.