“On 23rd April Miss Ryan’s treating consultant geriatrician received advice from the…”

The coroner’s concerns

– 1. On 23rd April Miss Ryan’s treating consultant geriatrician received advice from the infectious diseases team that a deep tissue biopsy was strongly recommended to best guide the antibiotic therapy for her infection. 2. Despite him liaising with/going back and forth between the Tissue Viability Nurse service, the Trauma and Orthopaedic team and the Plastic Surgery team (based at the Queen Elizabeth Hospital) between 23rd April and 1st May, none of these teams could, for different reasons, facilitate this procedure. As a result, it was not until 2nd May that assistance was sought from the interventional radiology team who agreed to help. 3. The procedure was initially due to take place on 7th May but had to be put off due to Miss Ryan being on warfarin and there were then further delays due to non-availability of the relevant specialist as well as the need to stop her existing antibiotics for 24 to 48 hours before the procedure. It was finally carried out on 21st May. 4. On 22nd May, a new anti-biotic regime was commenced with it being noted that one of the bacterial organisms identified from the biopsy, namely Morganella morganii, was resistant to co-amoxiclav, the antibiotic which Miss Ryan had most recently been receiving from 15th April until 19th May. 5. Although I heard evidence that the delay in starting the new antibiotic regime was unlikely to have altered the sad outcome in this case in part due to Miss Ryan’s existing frailty and poor prognosis, I am concerned that in the absence of any existing protocol regarding the correct specialism for the biopsy procedure, no Multi-disciplinary meeting bringing together specialists from the different disciplines was offered or held in this case to agree the best way forward. This led to a delay and a lack of collaboration between teams which could, if repeated, result in an avoidable death.

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, 2024-0632

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