The death of a 74-year-old woman from a severe reaction to an antibiotic which caused a 60% skin loss was "very, very rare" , southern regional coroner David Crerar says in his finding on the death.
He found Miriam Joy Kerr died at Dunedin Hospital on October 9, 2008 due to toxic epidermal necrolysis due to Cefalosporin antibiotic use.
The coroner was told a world database for adverse reactions to Cefalosporin showed there were only four patients recorded to have died from toxic epidermal necrolysis (Ten) as a result of the drug.
Ten is a condition where the top layer of skin becomes detached from lower layers.
Pathologist Dr Peter Fitzgerald and pathology registrar Dr Deborah Clarke gave the opinion the cause of death was multi organ failure due to Ten which was most likely related to Cefalosporin use prescribed for her bronchopneumonia. The respiratory condition itself was also likely to have contributed to her death.
They described Ten as an unfortunate rare reaction which could not be predicted.
Mr Crerar said the death of Mrs Kerr was " very, very rare" and, although he had made recommendations to " hopefully address" some issues identified, he noted " the practice of medicine will never be able to reach perfection".
"There will always be such rare events and no organisation or person can have blame attributed to him or her or them for such outcomes." He agreed with Mrs Kerr's daughter, Lynette, that her mother's rapidly deteriorating condition could have been and should have been recognised and acted upon earlier than it was.
Mrs Kerr, who had complex health conditions, was a resident at St Andrew's Home and Hospital in Dunedin before her death in 2008.
She was prescribed Cefaclor (CeClor) for a chest infection, but this was stopped after two doses on September 29 and September 30 because of the appearance of a rash with blisters.
General practitioner Dr Roy Morris examined Mrs Kerr on October 1 and, noticing the spread and severity of the rash, confirmed the discontinuance of the antibiotic and increased the amount of the steroid prednisone prescribed.
This medication was not given.
Miss Kerr stated the prednisone was important because it was the one drug that had the potential to help her mother counteract the effects of the allergy and any other illness.
Mr Crerar said although he did not receive evidence on the point, he made the observation Mrs Kerr's physical condition was compromised by her "existing co-morbidities".
A more robust person might not have reacted as Mrs Kerr did or a "stronger patient may have been able to tolerate and fight off infection".
Dr Morris advised he attended St Andrew's very early on October 2 and at that time there did not appear to have been an update of Mrs Kerr's condition in the nursing notes.
If he had been made aware of the major change in her condition, he would have immediately referred her to specialist support.
Mrs Kerr was admitted to Dunedin Hospital on October 3 and died six days later.
The coroner said the evidence he had been able to consider established Mrs Kerr suffered a most serious and extremely severe reaction " it must be assumed , to Cefaclor(CeClor)".
Mr Crerar said, as with so many cases considered by a coroner, there were a number of contributors to the death.
Miss Kerr had, "in a most able manner", identified shortcomings in caregiving and particularly in record-keeping, he said.
She had raised concerns about the allergy-charting process, which were acknowledged by the clinical leader of Dunedin Hospital's internal medicine department, Dr Brendan Rae.
It was of concern that known allergies to Augmentin, a penicillin-based antibiotic, and to morphine were not continually charted on Mrs Kerr's records, although " probably these shortcomings do not constitute 'a circumstance of the death'."
About 10% of patients reacted to antibiotics of both the penicillin and cefalosporin family.
Mr Crerar said expert opinion from gastrointestinal surgeon Richard Stubbs, of Wellington, stated it would be a very common practice for cefalasporins to be given to patients known to have a previous allergy to penicillin.
Mr Stubbs said in 32 years of surgery he had no memory of dealing with or treating a patient with Ten and did not feel that " even the example of the tragic death" of Mrs Kerr would justify the prohibition of the use of cefalasporins in patients allergic to penicillin.
Mr Stubbs acknowledged Miss Kerr's concerns about a skin rash on her mother following a previous administration of Cefaclor (CeClor).
However, most allergic reactions were not fatal and Mr Stubbs " urges against me creating or facilitating rules that would restrict the use of appropriate antibiotics", Mr Crerar said.
The coroner, whose findings were released this month following a hearing a year ago, recommended Dunedin Hospital give attention to a programme to address the problems with the charting of drugs and recording adverse reactions and cross-reactions.
It is understood work has been done on this, and the hospital is preparing a statement for the Otago Daily Times detailing this.
He also asked that a copy of the finding be sent to the Centre for Adverse Reactions Monitoring and the Intensive Medicines Monitoring Programme of the pharmaco vigilance centre at the University of Otago to ensure that the risk factors associated with Cefaclor (CeClor) and cefalasporins generally were recorded.
A copy was also to be sent to St Andrew's.
