Freda Weston
23 Feb 2016 · Coroner John Pollard · Manchester (South)
The coroner's concerns
1. discharged patient on Septrin
“She was discharged from hospital after being started on the Septrin without allowing sufficient time to ensure that the new drug”
2. teicoplanin administration delay
“She was advised for teicoplanin on the 8”
3. 48 hour antibiotic delay
“There was a 48 hour delay in her being given any antibiotics”
4. insufficient doctor time
“The junior doctor gave evidence that s/he was unable to”
5. perceived poor case rating
“In general terms the matron reporting the Root Cause Analysis agreed that on a scale of one to ten, where one is appalling and ten is excellent,”
6. iBleep escalation guideline non compliance
“The "Escalation guidelines for the iBleep system were either unknown to the staff or were not adhered to”
Responses
Weston-Response.pdf ↗· Stockport NHS Foundation Trust
Stated action
“We have used Septrin routinely in this Trust for step-down oral treatment for many intra- abdominal infections for about 5 years and this is the first time we have had a serious incident associated with its usage. The Antibiotic Management Team (microbiologists and antibiotic pharmacists) have discussed the future of Septrin usage and they do not feel it appropriate to change our current practice, as the alternatives would be more risky in terms of C.difficile and antibiotic resistance.”