Communication and Safety Fatality Report

Poor communication blamed for Claire Allnutt’s death

Poor communication between doctors and nurses has been blamed for the death of a 28-year-old woman, who died when her catheter became infected.

Claire Allnutt was admitted to Luton and Dunstable Hospital in November and was treated for a flesh-eating disease.

She died on 29 January, five days after it was noticed that her catheter needed replacing.

Coroner Thomas Osborne said she developed septicaemia in the three days before the catheter was taken out.

Recording a narrative verdict, he told the court in Ampthill that there was “a failure in the system of observation, monitoring and documentation of her deteriorating condition that resulted in a lost opportunity to render further medical attention”.

Ms Allnutt, from Luton, had been treated for necrotizing fasciitis and also had a history of morbid obesity and depression.

She was also unable to speak, having had a tracheotomy.

Some of the doctors said at times Ms Allnutt had been difficult to deal with and initially did not consent to the infected tube being removed.

But senior sister Julie Caunt told the court there “was never a sense of urgency” about her treatment, despite Ms Allnutt having a temperature of 39C on 25 January.

The court heard that part of the issue was the infection was spotted on a Friday, which the coroner said was the “worst time for this to happen”.

Medical director Dr Mark Patten said Ms Allnutt’s death “led to a lot of soul searching at the hospital about the prevention of infection”.

Ms Allnutt’s mother, Ann Allnutt, said her daughter had overcome the disease for which she was admitted to hospital and was due to be discharged.

Her father, Richard Allnutt, said: “There was a total lack of communication between the doctors and nursing staff.”