Coroner writes to Milton Keynes Hospital over 'significant missed opportunities' to treat infection which killed grandmother

A coroner is to write to Milton Keynes hospital after an infection contributed to the death of a grandmother who was admitted after she fell over a clothes horse.Yvonne Luck, 76, split her knee open, lost a lot of blood and badly bruised her hip at her home in Hanslope in the city.She was taken to Milton Keynes University Hospital on the 2nd November 2022 and died there on the 9th November 2022.Yesterday /Weds the assistant coroner for Milton Keynes Dr Sean Cummings said it was likely she arrived at the hospital with an established infection which worsened.He said there was “a lack of appropriate professional curiosity with regard to possible infection and there were significant missed opportunities to effectively treat her infection.”The Coroner noted difficulty in identifying a cause of death as there was no Post Mortem and a lack of investigations by the Trust but concluded that the "least unlikely" cause of the terminal event was a Pulmonary Embolism.He said the cause of death was Pulmonary Embolism - a blood clot in the lungs. He said the underlying cause was a fall together with a likely chest infection. The corner found that an irregular heart beat, chronic obstructive pulmonary disease and frailty contributed to the underlying cause.Mr Cummings said he was concerned that Mrs Luck’s clinical notes seemed to generate confusion in staff using them and will be writing a Coroner’s Letter to the Hospital.He said: “The use and prescription of antibiotics was of a poor standard with initial use of a drug to which she was allergic, then the excess use of a drug which has potential to be toxic to the kidneys in excess, then a failure to provide her with any antibiotics for a period of 22 hours because of difficulties with venous access. “ He also said there were significant missed opportunities to effectively treat her infection.The coroner said it was difficult to understand how a casual approach was allowed to develop in her treatment.He went on to say: “I am concerned that the clinical notes seem to generate confusion in staff using them, but that is a matter which is already the subject of discussions between the Coroner service and the Hospital.”He did not issue a Prevention of Future Deaths Notice.Helen Thompson from Fieldfisher, representing the family at inquest, said: “It's hugely distressing for Yvonne's family to hear that her death was contributed to by infection and that there were missed opportunities to treat her infection .“There were clearly major issues around lack of administration of effective antibiotics that might have prevented the infection from progressing. It is heartbreaking that with better care she could still be alive.“I am repeatedly asked to represent families where infection leading to sepsis has been misunderstood and mistreated by medical staff despite widespread awareness raising across the NHS nationally.”In March Dr Cummings found that father-of-two Alex Blewitt’s death from sepsis was avoidable after he had been sent home from Milton Keynes hospital with antibiotics for a suspected urinalysis tract infection. He issued a Prevention of Future Deaths report.In April 2021 the same coroner issued a prevention of further deaths report after finding that the hospital did not follow sepsis guidance in the case of 47-year-old Nicholas Rousseau.