Theresa Thompson

Date of report: 7 April 2017 Ref: 2017-0110 Deceased name: Theresa Thompson Coroners name: Elizabeth Carlyon Coroners Area: Cornwall and Isle of Scilly Category: Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent to: Public Health England

REGULATION 28: REPORT TO PREVENT FUTURE DEATHS

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS

THIS REPORT IS BEING SENT TO: The Director of Public Health England

CORONER

lam Dr Elizabeth Emma Carlyon, Senior Coroner for the coroner area of Cornwall and Isles of Scilly

CORONER'S LEGAL POWERS

| make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.

INQUEST

Theresa Mary Thompson died on the 9"" October 2016 at the Royal Cornwall Hospital, Treliske, Truro while on holiday in Cornwall. An inquest was opened on the 14" October and concluded at Truro Municipal Buildings, Truro on 29"" March 2017 with a conclusion of Natural Causes

CIRCUMSTANCES OF THE DEATH

Theresa Thompson underwent a Splenectomy when she was child in 1958 because of familial Acholuric Jaundice. Following the procedure she was advised on the need for indefinite prophylaxis with antibiotics to redress the risk of infection due to the reduction in efficiency of her immune system following the removal of the spleen. Mrs Thompson at some point declined antibiotics. In March 2013 she underwent ventriculo-peritoneal shunt. She developed sigmoid perforation and peritonitis in June 2013 and the infected ventriculo-peritoneal shunt was removed in Kings College Hospital, London. A new ventriculo- peritoneal shunt was re-inserted at Kings College Hospital, London on 8” August 2016 without prophylaxis antibiotics. She went on holiday to Cornwall and whilst on holiday she was admitted to the Royal Cornwall Hospital, Treliske, Truro on 8" October 2016 with sepsis from a Streptococcus pneumonia infection from which she died on 9" October 2016.

A post mortem was carried out and the cause of death was established as 1a Multi-organ failure 1b Sepsis 1¢ Streptococcus Pneumonia II Ventriculo- Peritoneal Shunt for Normal Pressure Hydrocephalus, Previous bowel Perforation in 2013 with peritonitis, Splenectomy as child.

CORONER'S CONCERNS

During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duly to report to you.

The MATTERS OF CONCERN are as follows. —

At the inquest, the pathologist advised that Streptococcus pneumonia infections were typical for patients having undergone splenectomy. The spleen was an important immune defence organ for this type of bacteriae. Usually patients were given a vaccination to prevent this type of disease and life-time antibiotic prophylaxis. Both the Pathologist and Treating clinician at the time of death, expressed concerns to the inquest that Mrs Thompson was not on prophylaxis antibiotics and that she had no antibiotic prophylaxis cover for her recent procedure especially as the Streptococcus infection was Serum type 6C for which there was no currently available pneumococcal vaccines (Reference report from Public Health England, Colindale, The Respiratory and Vaccine Preventable Bacteria Reference Unit I(RVPBRU).

The GP gave evidence that Mrs Thompson had been advised about inoculation and taking life-long antibiotic prophylaxis but at some point had declined (although there were no written records to support his evidence in her medical note). There was no evidence that she was advised or prescribed antibiotics prior to or after her Ventriculo-Peritoneal Shunt procedure in August 2016 at Kings College Hospital.

The family acknowledged that a number of the family had had a splenectomy due to familial Acholuric Jaundice but they were unsure that the family members appreciated the necessity for inoculation or prophylaxis antibiotics. They were concerned that there were mixed messages being given out by the Health Agencies about the use of antibiotics and the need to not overuse antibiotics and this had led to them not being inoculated or accepting life time prophylaxis antibiotics or the necessity of cover during medical procedures (if they had been advised at all).

ACTION SHOULD BE TAKEN

In my opinion action should be taken to prevent future deaths and | believe you [AND/OR your organisation] have the power to take such action.

To ensure that there is clear medical advice provided to Health Agencies and professionals and patients as to actions to reduced risk of infection in cases where a patient's immune system may be compromised such as after a splenectomy, radiotherapy and the recommended risk reductions treatment such as prophylaxis antibiotics, inoculation.

YOUR RESPONSE

You are under a duty to respond to this report within 56 days of the date of this report, namely by 29" May 2017. |, the coroner, may extend the period.

Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed.

COPIES and PUBLICATION

| have sent.a copy of my report to the Chief Coroner and to the following Interested

Persons}

Consultant in Public Health at Cornwall Council, — Consultant Neurosurgeon at Kings College, Hospital who may find it useful or of interest.

| am also under a duly to send the Chief Coroner a copy of your response.

The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

[DATE] [SIGNED BY CORONER] Cahkca

07.04.2017 Clagorlatlt Erayrc, Cony :