Ear infection death leads to calls for reviews at three hospitals
'Not followed-up'
In a prevention of future deaths report, Mr Spinney said Mr Tizard-Varcoe had a "complex past medical history" and was also being treated at Musgrove Park for a vascular condition.He said evidence at the inquest had highlighted occasions where Mr Tizard-Varcoe had been treated without the full clinical picture being available due to the inability of the trusts to access each other's medical records.Mr Spinney said there had also been three occasions when Mr Tizard-Varcoe was not followed-up as an outpatient in a timely manner.He added on 1 November, 2021, Mr Tizard-Varcoe left hospital in Exeter - which is run by Royal Devon University NHS Foundation Trust along with North Devon District - without an oral antibiotic prescription despite advice from microbiologists to have one.The inquest heard this was a clinical decision made by a junior ear, nose and throat (ENT) doctor and the discharge was overseen by a consultant from a different specialism due to Mr Tizard-Varcoe's health needs at the time.At the inquest, an ENT consultant indicated he probably would have prescribed antibiotics based on the microbiologists' advice.
Three recommendations
Mr Spinney said: "Due to the progression of the infection from the ear canal into the bone at the base of the skull, there is a real possibility that the clinical presentation did not reflect the true situation and this was a missed opportunity to provide continuity of treatment."Mr Spinney made three recommendations for action to be taken following Mr Tizard-Varcoe's death.This included that the trusts involved should consider reviewing their processes for managing patients with multiple health conditions being treated at different locations.He said this could help "ensure greater co-ordination, collaboration and optimal treatment".Mr Spinney also recommended a review into arrangements for follow-up outpatient appointments in the ENT departments at both trusts.His final recommendation said Royal Devon University NHS Foundation Trust should review its arrangements for patients' discharge in circumstances where a patient is being treated across different specialisms to ensure there is consultant oversight in all areas of treatment.
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