The tragic death of Claire Allnutt, 28, has resulted in changes at the Luton & Dunstable Hospital

Posted 29/10/2014

When Claire Allnutt was 28 years old she developed a serious condition called necrotizing fasciitis (often called the flesh eating bug) and she was admitted to the Luton & Dunstable Hospital on 11^th November 2013 for treatment.  Claire required several operations to treat the condition and was administered antibiotics through a peripherally inserted central catheter (PICC line).  Claire was doing well and plans were being made to discharge her from hospital.  However, despite the fact that she was recovering from her illness, Claire died from septicemia on 29^th January 2014. 

An inquest into Claire’s death was held on 15^th October 2014.  The inquest heard that on Friday, 24^th January 2014, Claire’s PICC line was found to have fungal spores and the Microbiologist advised a junior doctor that the PICC line should be removed.  The junior doctor recorded in the notes that she had spoken to the registrar and the registrar would speak to the consultant.  However, there is no record in the notes by either the registrar or the consultant to say that this conversation took place.  

The following day, Saturday, 25^th January2014, a second junior doctor was advised by the Microbiologist to take the PICC line out.  This second junior doctor saw the note from the previous day and thought a plan was in place to remove the PICC line and took no action. 

On Sunday, 26^th January 2014, a third junior doctor then came on duty and read the note incorrectly as he thought it said “PICC line cult” and he therefore proceeded to take a culture of the PICC line but it was not removed.

On Monday, 27^th January 2014, Claire was seen by a second registrar and this is the first time it is documented that she was asked for consent to remove the PICC line.  Claire was unable to speak at this point and was therefore only able to communicate by writing down her comments.   As Claire had learning difficulties and a needle phobia she initially refused removal of PICC line.  However, it was not until later that day that Claire’s partner was spoken to so that her consent could be obtained. 

On Tuesday, 28^th January 2014, a nurse recorded that the PICC line came out sometime that morning.  However, it was only a few hours later that Claire suffered a cardiac arrest due to the life-threatening septicemia.   Claire suffered several further cardiac arrests and she sadly passed away in the early hours of 29^th January 2014.

Following hearing evidence, the coroner gave the following narrative verdict:

“Claire Elizabeth Allnutt was admitted to the Luton & Dunstable Hospital on 11^th November 2013 with a groin abscess which developed into necrotising fasciitis.  On the 24^th January 2014 her peripherally inserted central catheter became infected and the Microbiologist advised that it should be removed.  There was a failure to remove the line until the 28^th January 2014 and the delay resulted in her developing sepsis.  There was also a failure in the system of monitoring, observation and documentation of her deteriorating condition that resulted in a lost opportunity to render further earlier medical attention and she died at 04:17 hours on 29^th January 2014.”

The coroner noted that “as a result of Claire’s death and the inquest there have been marked changes in the procedures and systems at the Luton & Dunstable Hospital.”

Carole Watts, Medical Injury Solicitor at Ashtons Legal commented that “Throughout the period from 24^th January 2014 to 28^th January 2014, there seems to have been no urgency by the doctors or nursing staff to make sure that the PICC line was removed and the advice of the microbiologist was followed.  It also appears that observations recorded in the electronic observation recording system which suggested a deteriorating situation were not escalated.

In Claire’s case it seems that a number of errors resulted in the final tragic outcome and it highlights the importance of good communication between medical staff, training, adequate weekend cover, following instructions and advice, supervision of junior doctors, and the need to act upon worrying observations and recognizing a deteriorating condition.  

Although the Luton & Dunstable Hospital have confirmed that since Claire’s death they have made changes to their  systems and procedures this has all come too late for Claire and her family.  Claire’s life was tragically cut short and it can only be hoped that the changes that have been made at the hospital will prevent similar deaths from occurring again.”