Before HM Senior Coroner Christopher P Dorries OBE, Sheffield Coroner’s Court. Narrative conclusion handed down on 11 December 2017.
Rory Badenoch represented the family of the Deceased, Kay Morrison, at a 4-day inquest into the circumstances of her death at the Royal Hallamshire Hospital in Sheffield on 21 June 2015. The Coroner concluded that the failure to take and act upon a proper history of multiple antibiotic treatments in the past materially contributed to her death from sepsis.
Although this was not a case in which Art 2 of the European Convention of Human Rights was formally engaged, Coroner Dorries found the distinction in this inquest to be academic as the issues considered would have been the same if Art 2 had been formally engaged.
Kay Morrison was a 47-year-old nurse who suffered from relapsing, remitting, multiple sclerosis. She had an extensive history of bladder complications and recurrent urinary tract infections (UTIs) for which she had been heavily pre-treated with courses of antibiotics. She had also grown E.coli in cultures taken in June, October and December 2014 which were reported as being highly resistant Extended Spectrum Beta-Lactamase [“ESBL”] producing organisms.
She was admitted to Royal Hallamshire Hospital on 10th June 2015 for a full cystectomy with fashioning of an ileal conduit.
Notwithstanding (a) her extensive history of UTIs which had been repeatedly treated with antibiotics, and (b) the positive cultures for ESBL producing organisms, microbiologists were not consulted prior to the operation about the appropriate prophylactic antibiotics to administer.
The history would have shown that the two prophylactic antibiotics initially prescribed (cefuroxime & metronidazole) were proven to be ineffective against the infective organisms Kay had previously grown.
Following surgery there was a significant deterioration in Kay’s condition, and there were delays in conducting a senior review.
On 14th June, Kay was suspected to be suffering from sepsis and, following a discussion with microbiology, the antibiotics were changed from cefuroxime and metronidazole to Tazocin, another drug that was known to be ineffective against the ESBL producing organisms which Kay had cultured on three separate occasions over the previous year. An exploratory laparotomy was conducted which revealed a significant wound infection with 100mls of pus.
A swab was taken which proved to be positive for the same ESBL producing organisms she had previously grown. It was not until 15th June that an appropriate antibiotic (meropenem) was administered.
Notwithstanding the draining of the pus and the administration of appropriate antibiotics, Kay’s condition continued to decline and she developed a fungal infection, and went on to suffer septic shock, cardiac arrest and hypoxic ischaemic brain injury before her death on 21 June 2015.
The post mortem (with which the Coroner agreed) concluded that Kay had died from 1a. cerebral ischaemia and multi organ failure and 1b. Post-operative sepsis.
The learned Coroner found that as a result of a failure to obtain a complete antibiotic history there had been a lack of effective antibiotic administration both prophylactically and in treatment. “With some little reluctance” he concluded that the lack of a proper antibiotic history could not be regarded as a “gross failure” (so as to justify a finding of neglect). However, in his view it was a “serious failure” and a “serious omission”.
He concluded that administration of inappropriate antibiotics arising from this serious failure materially contributed to Kay’s death occurring “when it did”.
A Narrative Conclusion was handed down as follows:
“Mrs Morrison underwent necessary surgery on the 11th June 2015 at the Royal Hallamshire Hospital in 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 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.”
Discussion – the importance of expert evidence:
Medically, this was an extremely complex inquest, involving clinicians from multiple disciplines. It was not made any easier by the fact that the Trust had not conducted a serious untoward investigation inquiry or produced a report, and there was no recognition of any deficiency in antibiotic treatment prior to the inquest. In fact, the material deficiencies in care that were identified by the Coroner were only brought to the Court’s attention by the independent medical experts.
Given the complexity of the case Senior Coroner Dorries sensibly obtained a steering report from a physician to narrow down the disciplines in which expert evidence was required. He initially limited expert evidence to a Consultant Urologist and a Consultant Intensivist, refusing the Family’s application for an expert microbiologist to deal with the issue of causation. However, following the evidence of the expert Intensivist, and having kept an open mind on the issue, he invited the family to re-apply for expert microbiological evidence and granted the subsequent application. The subsequent microbiological report proved central to his findings.
This case highlights the importance of obtaining independent medical expert evidence during the inquisitorial process. But for the expert evidence obtained in this case (and a Coroner who was prepared to keep an open mind to the need for additional expertise where necessary) the central issue of the inappropriateness of the antibiotic prophylaxis administered to Kay would almost certainly not have been identified.
NHS Trusts are invariably represented by experienced lawyers who have the Trust’s own doctors to assist them with understanding the medicine. By contrast the majority of families cannot afford to instruct lawyers or experts to assist them in the Coroner’s Court. Public funding for families during inquests is rare. The imbalance is stark.
Accordingly, in the absence of expert evidence, if the Trust at which a patient dies does not identify possible areas of concern, the potential for inadequate investigation and therefore injustice is very great.
The importance of independent expert evidence to a full and thorough, and most importantly fair, investigation (as highlighted in this case) cannot be underestimated. Sadly, the Coroners’ Courts are rarely as willing (or in fairness able – due to their limited resources) as Coroner Dorries was in this case to order expert evidence funded by the public purse.