Rachael Ryan

I am Simon Brenchley, Assistant Coroner for Birmingham and Solihull

On 11 July 2024 I commenced an investigation into the death of Rachael Alicia Elizabeth RYAN. The investigation concluded at the end of the inquest. The conclusion of the inquest was; Natural causes

Miss Ryan was discharged from Birmingham Heartlands Hospital on 27th February 24  following a period of treatment after a fall at her home against a background of  osteoarthritis. On discharge she was cared for at home in bed with a package of care  provision and was also receiving district nursing input for some moisture associated skin  damage to her buttocks which had developed post discharge from hospital. She was also  receiving treatment from her GP for suspected cellulitis in her legs. On 25th March 2024 she was readmitted to Heartlands Hospital because she was in great pain. When assessed after  her admission to A and E, it was found that she now had a Category 3 pressure ulcer on her buttocks/sacral area. On 26th March tests revealed she had a deep vein thrombosis in her  left leg and a scan on 27th March revealed a pulmonary embolism. Subsequently, on 5th  April it was suspected that her pressure ulcer may be infected so she was started on  antibiotics. A scan on 9th April revealed that she now had contracted osteomyelitis. Advice  was subsequently received on 23rd April from the infectious diseases consultant that Miss  Ryan needed a deep tissue biopsy in order to best inform the correct anti-biotic therapy.  Despite a number of different specialities being contacted to facilitate this, the biopsy could not be carried out until 21st May at which point the most appropriate anti-biotic therapy for  the particular type of infection she had was then identified and started. Although her skin  began to heal, she deteriorated on 11th June and despite continuing ongoing treatment she  passed away on 21st June 2024. Based on information from the Deceased’s treating clinicians the medical cause of death was determined to be: 1a Osteomyelitis 1b Infected Sacral Pressure Sore 1c 1d II    Frailty of Old Age

During the course of the inquest the evidence revealed matters giving rise to concern. In my  opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. –

1. On 23

rd 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.

1. 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 23

rd April and 1 st May, none of these teams could, for different  reasons, facilitate this procedure. As a result, it was not until 2 nd May that assistance was  sought from the interventional radiology team who agreed to help.

1. The procedure was initially due to take place on 7

th 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 21 st May.

1. On 22

nd 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 15 th April until 19 th May.

1. 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.

In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action.