Noreen McGlynn: Prevention of Future Deaths Report
Skip to related content
Date of report: 11/07/2025
Ref: 2025-0355
Deceased name: Noreen McGlynn
Coroners name: Mary Hassell
Coroners Area: Inner North London
Category: Community health care and emergency services related deaths
This report is being sent to: Mountfield Surgery | Central London Community Healthcare NHS Trust
| Regulation 28: Prevention of Future Deaths report | |
|---|---|
| THIS REPORT IS BEING SENT TO: 1. Senior Partner Mountfield Surgery 55 Mountfield Road Finchley London N3 3NR 2. Chief Executive Central London Community Healthcare NHS Trust Ground Floor 15 Marylebone Road London NW1 5JD | |
| 1 | CORONER I am: Coroner ME Hassell Senior Coroner Inner North London St Pancras Coroner’s Court Poplar Coroner’s Court Bow Coroner’s Court |
| 2 | CORONER’S LEGAL POWERS I make this report under the Coroners and Justice Act 2009, paragraph 7, Schedule 5, and The Coroners (Investigations) Regulations 2013, regulations 28 and 29. |
| 3 | INVESTIGATION and INQUEST On 5 February 2025, one of my assistant coroners, Ian Potter, commenced an investigation into the death of Noreen McGlynn aged 89 years. The investigation concluded at the end of the inquest yesterday. I made a determination of death by natural causes. |
| 4 | CIRCUMSTANCES OF THE DEATH Noreen McGlynn developed a throat infection and a urinary tract infection at home and was prescribed amoxicillin by her general practitioner. She suffered an anaphylactic reaction to this and was admitted to hospital. The reaction was reversed, but she died three days later from her underlying conditions. I recorded her medical cause of death as: 1a aspiration pneumonia 1b cerebrovascular disease and frailty of old age 2 anaphylaxis to penicillin. |
| 5 | CORONER’S CONCERNS 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. I heard at inquest that, even before her anaphylaxis Ms McGlynn was waiting for an ambulance to take her to hospital. This was on the advice of two GPs and with the agreement of her daughter. However, Noreen McGlynn’s family did not want her to go to hospital. They believed that she had a better chance of remaining well out of hospital. (The challenges that hospital admission present to the elderly are very well recognised.) And if she were now dying, family knew that Ms McGlynn would want to die at home. Her living situation was very supportive. She was a widow but she had an excellent full time carer and a loving, extremely engaged family, with her daughter living near by. The reason that family now favoured hospital admission was because Ms McGlynn had become so dehydrated. They recognised that this was life threatening and likely to make her feel unwell. If the rapid response team from the Central London Community Healthcare NHS Trust who visited, or the GPs from Mountfield Surgery, had been able to offer rehydration at home, this would have been a far preferable course of action for Noreen McGlynn and for her loved ones. Could such rehydration at home have been offered? Could it be offered to others in the future? |
| 6 | ACTION SHOULD BE TAKEN In my opinion, action should be taken to prevent future deaths and I believe that you have the power to take such action. |
| 7 | YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 8 September 2025. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed. |
| 8 | COPIES and PUBLICATION I have sent a copy of my report to the following. The daughter and son of Noreen McGlynn [REDACTED], Royal Free Hospital Royal College of General Practitioners Care Quality Commission for England Chief Medical Officer for England HHJ Alexia Durran, the Chief Coroner of England & Wales I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any other person who I believe may find it useful or of interest. The Chief Coroner may publish either or both in a complete or redacted or summary form. She may send a copy of this report to any person who she believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response. |
| 9 | DATE 11.07.25 SIGNED BY SENIOR CORONER ME Hassell |