“At the inquest, the pathologist advised that Streptococcus pneumonia infections were…”
Dated 7 Apr 2017, from the coroner for Cornwall and the Isles of Scilly. Sent to 1 organisation or person.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
Deadline passedReplies were due by 2 Jun 2017. A reply may have been sent and not yet published.
Organisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk.
- Report dated7 Apr 2017
- Deadline2 Jun 2017
- Published on judiciary.uk17 May 2017
- Today27 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Public Health England | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 2 Jun 2017. A reply may have been sent and not yet published. |
The coroner’s concerns
This report was published as a scan, so its text was read automatically. Check the wording against the original before you quote it.
— 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).
An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.
- Source
- judiciary.uk, Prevention of Future Deaths reports, 2017-0110
- Added to Minute Book
- 8 Oct 2026
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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0
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