Alec Mathias
PFD Report
Historic (No Identified Response)
Ref: 2015-0247
Coroner's Concerns (AI summary)
Critical drug sensitivity information was not included in discharge letters sent to the patient's GP, nor was it highlighted in hospital records, posing a significant risk.
View full coroner's concerns
(1) Discharge letters have not been sent to the patients GP in a case where a dangerous side effect to treatment has been noted (2) That the hospital has not highlighted its own records with vital information on drug sensitivity discovered and diagnosed on an in-patient
Sent To
Response Status
Linked responses
0 of 1
56-Day Deadline
21 Aug 2015
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 7h October 2014 commenced an investigation into the death of Alec James MATHIAS_ 78 years old. The investigation concluded at the end of the inquest on 24"h June 2015. The conclusion of the inquest was Misadventure with the Cause of Death of being Ia Liver Failure 1b Flucloxacillin Induced Cholestatic Liver Injury Ic Treatment for Cellulitis of the Left Index Finger Radiation Proctitis following Radiotherapy for Carcinoma of the Prostate
Circumstances of the Death
Mr Mathias suffered from a whitlow of his Left Index Finger in JunelJuly 2008 during which time he was treated with Flucloxacillin He was admitted to the Royal Devon Exeter (Wonford) Hospital on the September 2008 with a presumptive diagnosis of painless obstructive jaundice under Jfollowing a GP letter dated g"h September 2008 tc Consultant Gastroenterologist (see p.4 statement ofl dated 29.01.2015)_ It was found that he had suffered drug induced jaundice and the Flucloxacillin was stopped (further doses having been given while he was an in-patient): There is no record of a discharge summary being sent to Mr Mathias's GP or that he had suffered a reaction to the Flucloxacillin and that this had been the agreed cause of his liver problems. Mr Mathias suffered further infection of the index finger in August 2014 and was again prescribed Flucloxacillin by the GP practice nurse; which proved fatal see Record of Inquest and 10"h and received evidence from_ Fe September 2008 admission and and Iregarding the August 2014 admission and it is clear that not only was no discharge letter sent to the GP in 2008 alerting the practice to Mr Mathias's idiosyncrasy regarding Flucloxacillin but there was no highlighting of the hospital notes that he had an allergy or would suffer a reaction if given Flucloxacillin: The administration of Flucloxacillin has caused Mr Mathias's death.
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe you have the power to take such action:
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.