Christine Dickinson

I am Chris Morris, Area Coroner for Manchester South.

On 30 th November 2022, I opened an inquest into the death of Christine Mary Dickinson who died on 15 th November 2022 at Stepping Hill Hospital, Stockport, aged 76 years. The investigation concluded with an inquest which I heard on 16 th June 2023. The inquest determined that Mrs Dickinson died as a consequence of:- 1)  a) Pneumocystis Jirovecii Pneumonia; b) Interstitial Lung Disease and Immunosuppression II) Lymphoma The conclusion of the inquest was a Narrative Conclusion to the effect that Mrs Dickinson died as a consequence of recognised complications of prescribed medication in conjunction with the effects of interstitial lung disease and lymphoma.

Mrs Dickinson had been diagnosed with Grade II Follicular Lymphoma and had been receiving treatment at the Laurel Unit with Rituximab. In August 2022, Mrs Dickinson was admitted to hospital with respiratory difficulties, and provisionally diagnosed with Hypersensitivity Pneumonitis which initially responded to treatment with steroids. Following her discharge, Mrs Dickinson was administered with Rituximab on the Laurel Unit once more. In October 2022, Mrs Dickinson was admitted to hospital for the final time and became gravely ill, dying on 15 th November 2022.

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 duty to report to you. The MATTERS OF CONCERN are as follows

1. During the course of the inquest, the court heard evidence that staff on the Laurel Unit previously used a variety of systems (including one system not routinely accessible by staff elsewhere in the hospital) to record the administration of Chemotherapy.
2. Whilst the Consultant Haematologist told the court the requirement to use a single method of recording administration of Chemotherapy has be reinforced, in view of the above together with the fact that details pertaining to another patient entirely appear to have been entered into Mrs Dickinson’s record from September 2022, it is a matter of concern that no recent audit has been undertaken in respect of record-keeping on the Laurel Unit.

In my opinion action should be taken to prevent future deaths and I believe you and your organisation have the power to take such action.