Mary Marshall
PFD Report
All Responded
Ref: 2015-0084
All 1 response received
· Deadline: 1 May 2015
Coroner's Concerns (AI summary)
A general lack of awareness among hospital staff and GPs about the importance of GDH positive results, which indicate Clostridium Difficile vulnerability, risks inappropriate antibiotic prescribing.
View full coroner's concerns
the course of the Inquest the evidence revealed matters giving rise to concern: In my opinion there is a risk that future deaths occur unless action is taken : During the Inquest evidence was heard that: A GDH positive result indicates vulnerability to the development of Clostridium Difficile infection_ The evidence indicated that there was a lack of awareness, in general, of the importance of GDH positive results in relation to the future prescription of antibiotics and the risk of the Mrs During will development of Clostridium Difficile infection. Furthermore there is a lack of awareness amongst General Practitioners in relation to GDH positive results_
iii. The evidence indicated that there were Hospital Trusts in the North West that did not inform General Practitioners of GDH positive results and it is believed that a similar problem may exist Nationwide. iv The Bolton NHS Foundation Trust has addressed the problem of awareness and procedures have been implemented with instruction to all medical staff to communicate information regarding the GDH positive results to General Practitioners and other providers of primary care: Furthermore there has been & discussion with the Bolton CCG Clinical lead regarding raising awareness of GDH positive results in primary care and the implications for future prescription of antibiotics. The Trust has drafted letters (copies attached hereto) to be sent to General Practitioners; immediately upon diagnosis of GDH positive results, to confirm the diagnosis and to confirm that the patient is an inpatient at the Hospital at the time of the writing of the letter. The Trust will share the diagnosis with the relevant CCGT, in real time, if the patient is not an inpatient In so far as inpatients at the Hospital are concerned the Bolton NHS Foundation Trust has established procedures whereby the Extramed is noted with the GDH positive results and the Hospital has initiated a ward clerk alert system at the beginning of each ward round confirming that a patient is GDH positive so that the prescription of antibiotics may take account of the positive results.
vi. The evidence raised concerns that future deaths will occur unless action is taken to review the above issues on a Nationwide basis.
iii. The evidence indicated that there were Hospital Trusts in the North West that did not inform General Practitioners of GDH positive results and it is believed that a similar problem may exist Nationwide. iv The Bolton NHS Foundation Trust has addressed the problem of awareness and procedures have been implemented with instruction to all medical staff to communicate information regarding the GDH positive results to General Practitioners and other providers of primary care: Furthermore there has been & discussion with the Bolton CCG Clinical lead regarding raising awareness of GDH positive results in primary care and the implications for future prescription of antibiotics. The Trust has drafted letters (copies attached hereto) to be sent to General Practitioners; immediately upon diagnosis of GDH positive results, to confirm the diagnosis and to confirm that the patient is an inpatient at the Hospital at the time of the writing of the letter. The Trust will share the diagnosis with the relevant CCGT, in real time, if the patient is not an inpatient In so far as inpatients at the Hospital are concerned the Bolton NHS Foundation Trust has established procedures whereby the Extramed is noted with the GDH positive results and the Hospital has initiated a ward clerk alert system at the beginning of each ward round confirming that a patient is GDH positive so that the prescription of antibiotics may take account of the positive results.
vi. The evidence raised concerns that future deaths will occur unless action is taken to review the above issues on a Nationwide basis.
Responses
Action Planned
NHS England will work with partners to explore ways to develop a wider understanding of C. diff testing and the implications of the results, including GDH testing. NHS England will also consider the specific circumstances of this case to determine if any further action is merited and explore methods to support local health communities in the reporting and sharing of information in relation to a patient's CDI status. (AI summary)
NHS England will work with partners to explore ways to develop a wider understanding of C. diff testing and the implications of the results, including GDH testing. NHS England will also consider the specific circumstances of this case to determine if any further action is merited and explore methods to support local health communities in the reporting and sharing of information in relation to a patient's CDI status. (AI summary)
View full response
Dear Mr Walsh Thank you for your letter following the inquest into the death of Mary Marshall: As a result of evidence heard at the inquest, you would like to see an increased awareness of the implications of Glutamate Dehydrogenase (GDH) positive results and of the need to prescribe appropriate antibiotics to reduce the risk and the occurrence of Clostridium Difficile infection. You raise several concerns relating to the understanding and handling of GDH positive results: a lack of awareness generally amongst medical staff of the importance of such results, a lack of hospital procedures to inform the patient'$ GP of GDH positive diagnosis and the need for all hospitals to record such diagnosis on patient' hospital records for the attention of treating clinicians. You request that we review the following issues: the awareness amongst all Health Practitioners of the significance of GDH positive results and the training of General Practitioners in relation to the relevance of GDH positive results, particularly in relation to the future prescription of antibiotics. the procedures in Hospitals to advise General Practitioners and Primary Care Practitioners of a GDH positive result by use of letters similar to the attached letters prepared by the Bolton NHS Foundation Trust (You provide a copy of the letter and GDH awareness sheet that Bolton NHS FT has developed and
which send to the GP of the patient who has been diagnosed GDH positive). whether hospitals have log, similar to the Extramed system at the Royal Bolton Hospital, recording GDH positive results in the hospital records and their procedures for such results to be brought to the attention of Clinicians at the beginning of every ward round. Your letter has been shared with leading Clostridium difficile infection (CDI) experts within Public Health England and antimicrobial specialists within NHS England. Whilst advise that no changes are currently made to existing guidance in this area , there are measures that are currently being taken and considered to improve information exchange and understanding of CDI The management of CDI can be complex as many factors need to be considered to achieve the best treatment for the patient Tests to identify Clostridium difficile (C. diff) form fundamental part of CDI management: This is outlined in the Department of Health'$, Updated guidance on the diagnosis and reporting of Clostridium difficile (2012) which outlines two types of tests, which when used in combination, will deliver the most accurate results for the detection of C. diff infection. This national two test screening protocol comprises GDH enzyme immunoassays EIA (or NAATIPCR) followed by a sensitive toxin EIA. If the first test (GDH or NAAT) is negative, the second test (sensitive toxin EIA) does NOT need to be performed. A third test (eg NAAT or PCR) may be optionally added to the algorithm to further identify samples from potential C. difficile excretors. Whilst a GDH positive result may identify the presence of C. diff, it does not identify whether the strain is toxigenic Or non-toxigenic and the additional toxin test outlined above is therefore required. In addition, colonised by C diff can provide some protection CDL Therefore, it is not entirely accurate to say that a GDH positive result indicates vulnerability to the development of C. diff infection. In Mrs Marshall's case, the absence of the information from a toxin test and other clinical information;, makes it difficult to determine whether or not amoxicillin was the most appropriate treatment: It is a reasonable choice of antibiotic to treat a chest infection in community care and, as outlined by NICE; Evidence Summary, Clostridium difficile infection: risk with broad-spectrum antibiotics (2015), it presents lower risk in relation to C diff compared to other broad spectrum antibiotics. they they being against
However; it is also possible that the patient could have developed CDI even without the use of amoxicillin due to the multi-factorial nature of CDI and the presence of other risk factors including; age, hospital admission, high dependency unit admission and likely administration of broad spectrum antibiotics. Furthermore, the Department of Health '$ guidance is purposely cautious with regards to the treatment of GDH positive, toxin negative patients due to the lack of robust evidence regarding best practice. For this reason our expert advisers have recommended that changes to the national guidance are not required. Nevertheless, appropriate information relating to patient's CDI status is essential for informing the most appropriate care and treatment Nationally work is already undertaken to ensure that this is recognised As part of NHS England'$ Antimicrobial Resistance (AMR) work programme; work has been undertaken to promote the importance of C diff testing This has been achieved in part by the delivery of three national AMR workshops and a national clostridium difficile study All materials will be made available on the NHS England Patient Safety Domain webpage http:Ilwwwengland nhs uklourwork-patientsafetylassociated-infections : The national workshops included session on Improving Antibiotic Prescribing in Primary Care and specific content about identifying past C diff infections. To ensure this work is developed further; and in light of the recommendations made; NHS England will work with partners to continue to explore ways to develop a wider understanding of C. diff testing and the implications of the results, including but not limited to GDH testing; In addition; NHS England $ patient safety team will consider the specific circumstances of this case to determine if any further action, over and above that already planned, is merited However, all future work must take account of the national algorithm for C diff testing and mitigate against the risk of unintended consequences, (which involve patients being treated inappropriately i.e as though bave CDI) if the implications of GHD positive results are miscommunicated Methods to support local health communities in the reporting and sharing of information in relation to a patient'$ CDI status will also be explored. More widely, NHS England is already working on ideas for improving the provision of information between hospitals and primary care upon patient discharge This will be informed by examples of best practice implemented locally and by consulting with relevant partners and subject matter experts to determine how information should be disseminated: being day: may they
I would like to say how sOrry [ was to hear of Mrs Marshall's death and wish to extend my sincere condolences to her family: I hope that this response is helpful and [ am grateful to you for bringing the circumstances of Mrs Marshall's death to my attention:
which send to the GP of the patient who has been diagnosed GDH positive). whether hospitals have log, similar to the Extramed system at the Royal Bolton Hospital, recording GDH positive results in the hospital records and their procedures for such results to be brought to the attention of Clinicians at the beginning of every ward round. Your letter has been shared with leading Clostridium difficile infection (CDI) experts within Public Health England and antimicrobial specialists within NHS England. Whilst advise that no changes are currently made to existing guidance in this area , there are measures that are currently being taken and considered to improve information exchange and understanding of CDI The management of CDI can be complex as many factors need to be considered to achieve the best treatment for the patient Tests to identify Clostridium difficile (C. diff) form fundamental part of CDI management: This is outlined in the Department of Health'$, Updated guidance on the diagnosis and reporting of Clostridium difficile (2012) which outlines two types of tests, which when used in combination, will deliver the most accurate results for the detection of C. diff infection. This national two test screening protocol comprises GDH enzyme immunoassays EIA (or NAATIPCR) followed by a sensitive toxin EIA. If the first test (GDH or NAAT) is negative, the second test (sensitive toxin EIA) does NOT need to be performed. A third test (eg NAAT or PCR) may be optionally added to the algorithm to further identify samples from potential C. difficile excretors. Whilst a GDH positive result may identify the presence of C. diff, it does not identify whether the strain is toxigenic Or non-toxigenic and the additional toxin test outlined above is therefore required. In addition, colonised by C diff can provide some protection CDL Therefore, it is not entirely accurate to say that a GDH positive result indicates vulnerability to the development of C. diff infection. In Mrs Marshall's case, the absence of the information from a toxin test and other clinical information;, makes it difficult to determine whether or not amoxicillin was the most appropriate treatment: It is a reasonable choice of antibiotic to treat a chest infection in community care and, as outlined by NICE; Evidence Summary, Clostridium difficile infection: risk with broad-spectrum antibiotics (2015), it presents lower risk in relation to C diff compared to other broad spectrum antibiotics. they they being against
However; it is also possible that the patient could have developed CDI even without the use of amoxicillin due to the multi-factorial nature of CDI and the presence of other risk factors including; age, hospital admission, high dependency unit admission and likely administration of broad spectrum antibiotics. Furthermore, the Department of Health '$ guidance is purposely cautious with regards to the treatment of GDH positive, toxin negative patients due to the lack of robust evidence regarding best practice. For this reason our expert advisers have recommended that changes to the national guidance are not required. Nevertheless, appropriate information relating to patient's CDI status is essential for informing the most appropriate care and treatment Nationally work is already undertaken to ensure that this is recognised As part of NHS England'$ Antimicrobial Resistance (AMR) work programme; work has been undertaken to promote the importance of C diff testing This has been achieved in part by the delivery of three national AMR workshops and a national clostridium difficile study All materials will be made available on the NHS England Patient Safety Domain webpage http:Ilwwwengland nhs uklourwork-patientsafetylassociated-infections : The national workshops included session on Improving Antibiotic Prescribing in Primary Care and specific content about identifying past C diff infections. To ensure this work is developed further; and in light of the recommendations made; NHS England will work with partners to continue to explore ways to develop a wider understanding of C. diff testing and the implications of the results, including but not limited to GDH testing; In addition; NHS England $ patient safety team will consider the specific circumstances of this case to determine if any further action, over and above that already planned, is merited However, all future work must take account of the national algorithm for C diff testing and mitigate against the risk of unintended consequences, (which involve patients being treated inappropriately i.e as though bave CDI) if the implications of GHD positive results are miscommunicated Methods to support local health communities in the reporting and sharing of information in relation to a patient'$ CDI status will also be explored. More widely, NHS England is already working on ideas for improving the provision of information between hospitals and primary care upon patient discharge This will be informed by examples of best practice implemented locally and by consulting with relevant partners and subject matter experts to determine how information should be disseminated: being day: may they
I would like to say how sOrry [ was to hear of Mrs Marshall's death and wish to extend my sincere condolences to her family: I hope that this response is helpful and [ am grateful to you for bringing the circumstances of Mrs Marshall's death to my attention:
Sent To
- Department of Health and Social Care
Response Status
Linked responses
1 of 1
56-Day Deadline
1 May 2015
All responses received
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Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On 5th September 2014, I commenced an Investigation into the death of Mary Magdalene Marshall; 87 years, born on the 26th May 1927. The Investigation concluded at the end of the Inquest on 23rd February 2015. The medical cause of death was: 1a) Pseudomembranous Colitis 1b) Clostridium Difficile Colitis The conclusion of the Inquest was that Mary Magdalene Marshall died as a consequence of a recognised complication of antibiotic therapy on background of Glutamate Dehydrogenase and naturally occurring disease: CIRCUMSTANCES OF THE DEATH Magdalene Marshall died at the Royal Bolton Hospital, Minerva Road, Farnworth, Bolton on the August 2014. In March 2013 Mrs Marshall was an inpatient at the Royal Bolton Hospital when she was identified as being Glutamate Dehydrogenase (GDH) positive from a faecal specimen:
3. A GDH positive result indicates vulnerability to the development of Clostridium Difficile infection_ The Royal Bolton Hospital had two systems to report a finding of GDH positive,_namely: - Mary 29th
The Ascribe Discharge summary which communicates findings to a General Practitioner, The Extramed which records the findings on the hospital records so that appropriate measures may be taken on any subsequent admission in terms of infection control
5. On the 13th August 2014 Mrs Marshall was seen by her General Practitioner who diagnosed a chest infection and prescribed Amoxicillin as a recommended antibiotic to treat the chest infection: On the 19th August 2014 Mrs Marshall was admitted to the Roval Bolton Hospital with tender swelling in the left inguinal region and a CT scan on the 20th August 2014 identified an incarcerated inguinal hernia causing small bowel obstruction. Marshall consented to surgery to repair the hernia but when she was transferred to the operating theatre, later the same evening, she suffered a cardiac arrest and required cardiopulmonary resuscitation; She was transferred to the High Dependency Unit when it was deemed too high a risk to proceed with the surgery and the small bowel obstruction was managed with conservative measures including intravenous fluid administration and nasogastric drainage.
7. On the 26th August 2014 Mrs Marshall developed an elevated temperature and a chest X-ray showed evidence of a right sided pneumonia, Appropriate antibiotic therapy was commenced along with chest physiotherapy. On the 28th August 2014 a stool sample confirmed Clostridium Difficile infection and, after discussion with the Consultant Microbiologist; Metronidazole was commenced as an appropriate antibiotic to treat Clostridium Difficile but Mrs Marshall continued to deteriorate and died on the 30th August 2013
3. A GDH positive result indicates vulnerability to the development of Clostridium Difficile infection_ The Royal Bolton Hospital had two systems to report a finding of GDH positive,_namely: - Mary 29th
The Ascribe Discharge summary which communicates findings to a General Practitioner, The Extramed which records the findings on the hospital records so that appropriate measures may be taken on any subsequent admission in terms of infection control
5. On the 13th August 2014 Mrs Marshall was seen by her General Practitioner who diagnosed a chest infection and prescribed Amoxicillin as a recommended antibiotic to treat the chest infection: On the 19th August 2014 Mrs Marshall was admitted to the Roval Bolton Hospital with tender swelling in the left inguinal region and a CT scan on the 20th August 2014 identified an incarcerated inguinal hernia causing small bowel obstruction. Marshall consented to surgery to repair the hernia but when she was transferred to the operating theatre, later the same evening, she suffered a cardiac arrest and required cardiopulmonary resuscitation; She was transferred to the High Dependency Unit when it was deemed too high a risk to proceed with the surgery and the small bowel obstruction was managed with conservative measures including intravenous fluid administration and nasogastric drainage.
7. On the 26th August 2014 Mrs Marshall developed an elevated temperature and a chest X-ray showed evidence of a right sided pneumonia, Appropriate antibiotic therapy was commenced along with chest physiotherapy. On the 28th August 2014 a stool sample confirmed Clostridium Difficile infection and, after discussion with the Consultant Microbiologist; Metronidazole was commenced as an appropriate antibiotic to treat Clostridium Difficile but Mrs Marshall continued to deteriorate and died on the 30th August 2013
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.