A pharmacist in training has admitted he ‘missed opportunities’ when he mistook a young mum’s sepsis symptoms for painkiller withdrawals – a diagnosis a court heard he was not qualified to make.
Sarah Dunn, 31, of Boothley Road, died of sepsis at Blackpool Victoria Hospital on April 11 2020, nearly four weeks after having a pregnancy termination.
Yesterday, an inquest heard how the mum of five probably came down with the potentially deadly infection after group A streptococcal bacteria entered her womb during the procedure on March 23.
She saw her GP, Dr Sanjeev Maharaj, at the now-closed Elizabeth Street Surgery on April 1 after experiencing increased vaginal bleeding, which a nurse had warned her about.
Blackpool town hall
But Dr Maharaj said he saw ‘no signs of infection’ at that time.
On April 9, Miss Dunn had a telephone consultation with pharmacist Anthony Lynn, when she complained of abdominal pain, sweating and nausea. He believed this was due to her running out of painkillers, as the mum-of-five was on a medication reduction programme pre-dating her pregnancy termination, which she had been placed on after suffering a broken wrist.
Her medical records, made by Dr Maharaj on April 1, noted the pregnancy termination she had undergone, however, Mr Lynn said he was not aware of this.
Coroner Louise Rae concluded: “That would indicate either you hadn’t read the correspondence on the consultation on April 1, or possibly had scanned it and not absorbed the information. Going into the phone call, your focus was on pain medication.”
She asked: “Had you seen or noted that consultation from April 1 which said that she had had a termination, would that have triggered a differential diagnosis from you?”
Mr Lynn said: “I would have called her in, or even insisted that she come in, and do her ops, and then I would have discussed my findings with the GP and taking advice from the GP thereafter.”
The court heard that Mr Lynn, who was placed at the surgery on work experience, was not qualified to make a diagnostic assessment of Miss Dunn when he spoke to her.
Mr Lynn said the surgery had an ‘open door policy’ where he could approach Dr Maharaj for advice at any time, but did not do so, and instead arranged a telephone appointment for Miss Dunn the following day.
He said: “At the time, I thought it was likely to be withdrawal and I thought it was important enough to get her the first available appointment with the doctor, but not necessarily important enough to knock on his door there and then.”
He added: “In hindsight, I can admit I had a missed opportunity with Sarah. At the time, I thought my reasoning was reasonable.”
Richard Baker, representing Miss Dunn’s family, said: “You are essentially making a diagnostic call. Given that’s a judgement that you were not qualified to make, you should have sought supervision straight away.”
Mr Lynn said: “In hindsight yes, I agree with you.”
Shortly after 2am on April 10, Miss Dunn made a desperate phone call to the NHS 111 service, when she told Dr Nishan Karunasekara that she had not eaten in five days, that she had not passed urine that day, and that she had ‘never felt so ill’. She had an intermittently high temperature and ‘very severe limb pain’.
Dr Karunasekara said: “Infection is always something that I consider, and I consider what is more or less likely. I thought in this case it was less likely because of the information I had at that time.”
He advised Miss Dunn to continue taking painkillers ahead of talking with her GP at her arranged telephone appointment later that morning.
“I could have brought her in to see myself at the organised care centre, but I would have had other cases to deal with. If I had been concerned that she needed emergency treatment, I would have advised that. But we were at that point in the pandemic, and I was mindful of not putting her at additional risk if an infection was less likely,” he said.
He added that he could have arranged an emergency home visit for Miss Dunn – but he was the only GP working that night, and doing so would have left the emergency care centre unmanned.
“Infection was low on the list of differential diagnosis,” he said. “If it was higher, I would have arranged a face to face review in possibly a clinical setting, but I had toconsider the other factors as well, about the limited availability of A&E at that time.”
Following the phonecall, Miss Dunn continued to deteriorate, and an ambulance was called just before 8am. She was taken to Blackpool Victoria Hospital, where she died the following day.
A HSIB investigation carried out after the death of Miss Dunn found that allied healthcare professionals were not adequately supervised at Elizabeth Street Surgery.
Mr Lynn, however, said: “At the time I felt I was being supervised appropriately.”
Richard Smith, representing Dr Maharaj, argued that a further CQC report highlighting failures at the surgery was ‘irrelevant’ to the coroner’s investigation as it had been published in May 2021, more than a year after Miss Dunn’s death, and pushed for the evidence to be thrown out.
He said: “By the time of this report Dr Maharaj was already handing over the contract for the Elizabeth Street Surgery. We have heard no evidence about the circumstances in which he came to do that. There has been no evidence as to whether there had been any changes in the time intervening. In my opinion the CQC report is irrelevant to this inquest.”
But Mr Baker said: “I would say there is a clear link between the HSIB report and the CQC report. One resonates very closely with the other. If the issues were unrelated, then I would agree what happens later is irrelevant. But in this case, what happens later is very relevant. What was being observed by the HSIB is clearly reflected by the CQC.”
Ms Rae ruled she would allow the CQC report to be taken into evidence.
Mr Baker said: “The practice was unable to demonstrate they had taken any action to improve to local and national averages. Systems of communication were not effective and the practice was unable to demonstrate that allied professionals were appropriately supervised.
“The report says that the practice could not demonstrate that there was an effective system of supervision for allied health professionals to ensure they were working within their competencies… There was additional evidence that the practice was unable to demonstrate evidence of clinical governance or leadership.”
The inquest continues.