Patient died after hospital prescribed medicine for an infection she didn't have

A woman died after being prescribed medicine for an infection she didn't have, an inquesthas heard.

Audrey Newman, who had suffered a seizure at home, was admitted to Stepping Hill Hospitalin Stockport on November 11 last year with suspected encephalitis - a serious condition that causes swelling of the brain. But she was not immediately given the vital lumbar puncture needed to confirm the diagnosis.

The inquest heard there was a "lack of competent ward doctors" to carry out the procedure, and a lack of consultant oversight meant the test was delayed for a week. In the meantime, Ms Newman was prescribed the antiviral drug acyclovir, which carries a "well recognised" risk of kidney failure.

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By the time the lumbar puncture was finally performed, she had already developed "severe renal failure which did not respond to treatment". The results later showed she did not have encephalitis. Ms Newman died on November 24.

An inquest held at Stockport coroners' court concluded Ms Newman "died from recognised risks of antiviral therapy for a suspected life-threatening condition". Assistant coroner Andrew Bridgeman has now issued a warning to the CEO of Stockport NHS Foundation Trust, urging action to prevent future deaths.

The inquest was told that had a lumbar puncture been performed the day after Ms Newman's admission, the negative results would "likely have been reported, within 24 hours, as negative and the antiviral and antibiotic treatment stopped".

Following an internal investigation into Ms Newman's death, known as a 'Lessons Learned Overview', the trust began training sessions to enable ward doctors to carry out lumbar punctures. But despite that Mr Bridgeman said there is still no formal process for requesting assistance if the procedure can't be carried out due to the patient being agitated or the unavailability of a trained doctor.

In a prevention of future deaths report he wrote: "The evidence of the Trust was that CSF analysis (the spinal fluid collected during a lumbar puncture) was CRUCIAL for diagnosing meningitis or encephalitis when infection is suspected. Further, acyclovir is well recognised as a drug giving rise to renal injury.

"The witness speaking to the LLO said that requests for escalation are still informal and based on goodwill. There is no formal process for requesting assistance. The issue of concern is that in the absence of a formal pathway or referral process to the anaesthetic team for those cases which fall into the above category there is a significant risk of future delays in carry out crucial diagnostic tests, and a risk of death."

A spokesperson for Stockport NHS Foundation Trust said: "We offer our sincere sympathy and condolences to Audrey Newman’s family at this sad time. We are reviewing the concerns of the coroner and we will be responding on these matters."