“Stevens-Johnson Syndrome is a dermatological emergency with a significant mortality rate…”

The coroner’s concerns

1) Stevens-Johnson Syndrome is a dermatological emergency with a significant mortality rate (perhaps over 10% in a man of Gordon’s age and frailty), he was referred with this diagnosis by an experienced GP. While evidence suggests a medical consultant was contacted he did not see Gordon himself and I heard no evidence to suggest a dermatologist was consulted for advice. Also the SCORTEN or ABCD-10 prognostic tools were not used, they may have been helpful. 2) When Gordon returned to A&E late on 20th January there was an excessive delay in his assessment. His blood test revealed a significant lactic acidosis with marked anaemia and very low white blood counts. The A&E consultant who gave evidence said she would have expected this to be escalated to her -she was on call at home, but it was not. I have inputted the data in medical records to the scoring tools referred to above and mortality predictions have now risen to around 50%. 3) Gordon had a CT scan, he was referred to medicine but not seen by a medical consultant until 4.30 pm, he was to be admitted to a ward (this happened at 6.30pm) but there is no record in the notes of the significance of the earlier blood test being appreciated. 4) At the inquest into the death of Nicholas Dietzold (who died in the A&E department) which I heard last September I was assured that a system of “Intentional Rounding” would take place in A&E when a senior doctor and nurse would go round the department to look at patients & assure themselves that appropriate actions were in hand (I am aware the design of the department is less than ideal). The consultant gave evidence assuring me that this did take place but there were no notes to confirm this and I question whether it is a robust system. 5) On the medical ward there still seems to be no sense of urgency in Gordon’s treatment. A further blood test at 8.45pm showed severe lactic acidosis and hyperkalaemia but no action seems to have been taken. It was not until the ICU doctor happened upon Gordon just before 11pm, 24 hours after he arrived in the hospital that positive steps were taken. 6) , Gordon’s wife was not permitted to be with him in A&E due to Covid restrictions. Thus he had no advocate. I have no doubt that had she been there to speak for him care would have been expedited. It is my view that regardless of policy severely ill patients will benefit from support in similar circumstances. 7) I was shown a “Mortality and Harm Review Tool” completed in May which concluded that “care was good and decisions sound”, and that there was no need for a Serious Incident Review. I stated in court that I completely rejected this. I did however note and am pleased that is producing an educational programme and Standard operating procedure for SJS/TENS.

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, 2022-0217

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