Inquest Archives

Inquest exposes continuing and dangerous risk of restricted items on mental health wards

A jury at Suffolk Coroner’s Court in Ipswich has delivered its conclusion in the tragic case of a Newmarket man who died while under in-patient care at a specialist mental health unit in West Suffolk. The six-day hearing followed a pre-inquest review last March.

HM Senior Coroner for Suffolk, Nigel Parsley, led the investigation into Joshua’s death on 9 September 2019. At the lengthy inquest, the jury concluded that 25-year-old Joshua Sahota died at Wedgwood House mental health unit in Bury St Edmunds as a result of asphyxia by deliberately placing a plastic bag over his head and using a bed sheet around his neck.

Lack of adequate risk assessment

The inquest heard that Joshua was a quiet young man who kept to himself. Staff only got to know him superficially, which limited their ability to assess the risk he posed to himself. Despite being classified as a high suicide risk throughout his admission, no effective measures were implemented to ensure his safety.

Joshua had previously attempted suicide by deliberately driving a car off a bridge onto the A14 near Newmarket. The jury was unable to determine his state of mind at the time of his death but highlighted several contributing factors including:

Insufficient staffing
Inadequate observations and 1-to-1 supervision
Poor documentation
Lack of access to a psychologist
Unclear restricted items policy

Prevention of future deaths report issued

The coroner has raised a ‘Prevention of Future Deaths Report’ not only with the Trust but also directly with the Minister for Mental Health and Patient Safety. This rare step underscores the severity of the restricted items issue at a national level.

Joshua’s admission to wedgwood house

Joshua was admitted to Wedgwood House, located at the West Suffolk Hospital site in Bury St Edmunds. Although the hospital site is under West Suffolk Hospital NHS Foundation Trust, Wedgwood House is managed by the Norfolk and Suffolk NHS Foundation Trust.

The Trust was previously rated as inadequate and placed under special measures in 2017 following a Care Quality Commission (CQC) review. Since November 2018, the Trust has faced 21 Mental Health Act monitoring visits, resulting in 96 required actions.

Unclear policies and inadequate staffing

The inquest exposed that the NHS Trust had no clear local policy regarding the possession of plastic bags, belts, shoelaces, and similar items on the mental health ward. Staff members followed inconsistent practices, leading to uncertainty around which items were permitted.

Additionally, the unit’s care plan for Joshua was deemed inadequate. On the day of his death, the ward was short-staffed, with only three members present instead of the required six. Staff also failed to conduct proper hourly observations, with no adequate observation of Joshua between 3:05 pm and 5:15 pm when he was found unresponsive.

Investigation findings highlight systemic issues

The Trust’s internal investigation further revealed serious shortcomings, including:

Lack of detailed risk assessments
Absence of professional curiosity
Inadequate psychological support due to a long-term shortage of staff
Poor holistic psychosocial assessment of Joshua
Risk management that failed to meet his needs

Confusion over restricted items was evident, with most staff believing plastic bags were not permitted. Despite discussions at a Trust patient safety meeting in October 2017 regarding plastic bags, no subsequent action was recorded.

Family response and call for improvements

Tees Law, representing Joshua’s family, stated that the inquest findings reflect concerns previously raised by Joshua’s father, Malkeet Sahota. These concerns were further exacerbated upon learning of other deaths at Wedgwood House in recent years.

“Joshua’s dad, Malk, and the family are incredibly grateful to the jury for their diligent and thoughtful conclusion, having heard detailed evidence over several days from numerous witnesses. Seeing that the jury recognised Joshua as an intelligent, polite, and well-loved young man is heartening.”

Malkeet Sahota has expressed a strong desire for systemic improvements in mental health care. He welcomed the coroner’s decision to raise a Prevention of Future Deaths Report to the Minister for Mental Health and Patient Safety, particularly regarding the communication of restricted item policies to families and visitors.

“The fact that the Coroner has raised concerns on a national level about restricted items on mental health wards and the importance of communicating these issues with families shows just how vital inquests like Joshua’s are,” Tees Law concluded.

Inquest concludes after Suffolk postmaster’s tragic hospital death

An inquest at Suffolk Coroner’s Court in Ipswich, conducted by Mrs. Catherine Wood, has heard evidence regarding care and service delivery issues while investigating the tragic hospital death of a 73-year-old man who had been admitted for treatment of a fractured hip.

Background

The patient, Barry Jefferson, had worked for many years alongside his wife Sarah at their Post Office Stores business in Thurston, near Bury St Edmunds. They were close to finalising plans to sell up and spend more time with family, including their young grandchildren.

On 17 August 2020, Barry tripped at home and fractured his right hip, which had previously been replaced. After relatively straightforward surgery was performed on the periprosthetic fracture at West Suffolk Hospital on 20 August, he was slowly recovering in the orthopaedic ward and appeared to be doing well.

Bloating and swollen abdomen

Placed in a side room due to a positive MRSA test, by 27 August Barry was unwell with nausea and vomiting. During the August Bank Holiday weekend, he told nurses he felt bloated and had a swollen abdomen. The nursing team consulted doctors on call, who prescribed medication for bloating.

Over the course of the bank holiday weekend, Barry became increasingly unwell. Despite repeated escalation from the nursing staff, he was only reviewed by very junior doctors, going five days without review or input from senior clinicians. In addition, following clinical reviews, documentation was often poor or missing, and there appeared to be a lack of understanding of the changing clinical picture.

On Tuesday 1 September, a review by the advanced nurse practitioner pointed to a possible infection, source unknown. At this stage, Barry had not been reviewed by a senior clinician since before the weekend, and there had been no proper investigations into his abdominal distension. Antibiotics and fluids were administered intravenously, but Barry became more unwell overnight and began vomiting.

A consultant conducted a further review in the afternoon and, suspecting a possible bowel obstruction, ordered nil by mouth and an abdominal X-ray. The X-ray that afternoon showed distended loops of small bowel consistent with an obstruction.

Following the X-ray and referral to the surgical team, Barry suffered further deterioration, and an emergency call was activated. Probable irreversible organ failure was suspected when he did not respond to resuscitation treatment by the emergency team. Sadly, he died a short time later.

Care and service delivery issues

Following Barry Jefferson’s death on 2 September, ultimately due to cardiac arrest, a Serious Incident Report was completed by West Suffolk NHS Foundation Trust. This identified a number of care and service delivery issues and pointed to several root causes.

“The report highlighted a series of delays in recognising deterioration in Barry’s condition during that fateful bank holiday weekend and tardiness in seeking senior reviews and investigations,” explains Tees Law, acting for widowed Sarah Jefferson.

“A more timely response earlier in the weekend might have led to a different outcome in this case. Establishing why things went so badly awry has not been helped by a repeated lack of documentation by the junior doctors who reviewed Barry, it being recorded during the inquest that the documentation fell far below what would have been expected from a junior doctor.

“Review by a senior clinician should have occurred sooner, with particular emphasis over the bank holiday weekend. This could have led to an urgent surgical review, with investigations such as the abdominal X-ray and nasogastric tube insertion occurring sooner.

The inquest heard from a senior member of the Hospital Trust who confirmed that the Trust had found that a lack of appropriate senior review over the Bank Holiday weekend led to a failure to recognise Barry’s deterioration, late investigation, and late treatment.

There was further found to be an inconsistent approach to the handover of patients out of hours, leading to poor communication between teams, failure to review or monitor for deterioration, and delay in escalation of a sick patient. The lack of a Sick List meant that patients who required close monitoring were not routinely monitored or reviewed.

Measures implemented

Following the Trust’s internal review, a number of measures have now been put in place, including a revised handover within the surgical division, use of a Sick List during handovers for general surgery and orthopaedic teams, development of a Standard Operating Procedure for a revised handover process, as well as shared learning in respect of escalation of patients and the importance of documentation to junior doctors.

A second ortho-geriatrician to the surgical division is also being recruited to work towards the Trust’s goal of every orthopaedic patient receiving a review by a senior doctor Monday to Friday, with senior surgical review out of hours as needed.

“Sarah Jefferson is grateful to the Coroner for the thorough investigation into Barry’s death. Hopefully, following the Hospital Trust’s findings and the measures that have been implemented since Barry’s death, the incidence of failures to escalate the response to clearly deteriorating patients will have been greatly reduced.”

Newborn baby boy’s death due to hospital neglect

An Inquest conducted by the Hertfordshire Coroner Service has concluded that aspects of the events leading up to the sad death in hospital of Eddie Coffey, a one-day-old baby boy were so unsatisfactory that they amounted to neglect.

The hearing at Hatfield learned that Eddie Coffey had died in the neonatal intensive care unit at Luton & Dunstable Hospital on 14 January 2019, having been transferred from the Lister Hospital in Stevenage due to major complications following his birth there the previous night.

Eddie’s 30-year-old mother, Hannah Coffey from Hoddesdon, already had a two-year-old child and was seven weeks pregnant with Eddie when, on 29 May 2018, she was assessed by the Lister Hospital as low-risk as regards antenatal care.

In August, Hannah’s history was reviewed during her visit to the hospital’s Consultant Clinic. She was already taking aspirin in view of raised blood pressure during her earlier pregnancy and she was to have third-stage active management with regular blood pressure checks from 24 weeks.

Delivery

On 13 January 2019, Hannah experienced contractions and was admitted to the midwifery-led unit at the Lister. Initial monitoring at 1815 showed that the fetal heart rate was within the normal range and it remained so for over four hours as contractions became more frequent.

At 2240, a large deceleration in heart-rate was noted and the Lister’s Consultant-led unit (CLU) was informed of this. Minutes later, Hannah was transferred to the CLU and a cardiotocograph (CTG) was commenced to monitor fetal heart rate and contractions.

Over the next 10 minutes fetal heart rate was recorded as within normal range, and birth was imminent, so a request for the Registrar to attend was cancelled. Eddie was delivered just before 2330, but his condition was concerning.

Resuscitation

The emergency buzzer was used to call for resuscitation and the neonatal team took over, with the Locum Registrar on call for Paediatrics attending.

Resuscitation was provided using an IPPV ventilator, with cardiac compression, until ETT intubation was ready at 2350. Eddie’s heart rate then fell further, prompting re-intubation with a narrower tube, and his heart rate improved.

At around midnight, the Neonatal Consultant arrived and tests of venous gas indicated metabolic acidosis, a serious electrolyte disorder. Eddie was transferred to the neonatal intensive care unit (NICU), where fluids and medication were administered while ventilation continued.

Suspecting hypoxic ischemic encephalopathy (HIE), a brain damage, the consultant arranged transfer to the NICU at Luton & Dunstable Hospital for possible therapeutic hypothermia treatment. Baby Eddie was transferred there in the early hours but sadly died later that day.

Cause of death

A post-mortem at Great Ormond Street Hospital found that the cause of Eddie’s death was perinatal asphyxia.

A Serious Incident Investigation by East and North Hertfordshire NHS Trust followed. The investigation report concluded that at a crucial time in the proceedings the CTG appeared to have recorded the mother’s heart rate, not the baby’s, thus preventing recognition of fetal hypoxia. This was likewise the opinion of independent expert evidence heard by the Coroner such that earlier identification of Eddie’s condition would have improved his outcome. Such a failing, the Coroner found, amounted to neglect.

“Correct, effective use and interpretation of a baby and mother’s heart rate is helped by a CTG machine but it still needs to be interpreted responsibly and then appropriately acted upon. Here the Coroner determined on all of the evidence that it was neglect to fail to provide such basic care to Eddie and that this may have avoided such a tragic outcome,” said specialist medical solicitor Tim Deeming of Tees Law, acting for parents Hannah and Thom Coffey. “The inquest has been very challenging for the family and whilst we understand that the Lister have been looking to improve, we want to ensure that this does not arise for any other family, especially given the findings from the national Each Baby Counts review and the concerns raised around such preventable outcomes.”

Hannah’s concern for others

“Saying goodbye to our beautiful boy only hours after he had been born has left us all with a hole in our hearts from which we will never recover,” Hannah Coffey reflects.

“Not for a moment did I imagine that we could arrive at hospital with a healthy baby and leave without him in our arms. Like many expectant parents we put our trust in the care we would receive.

Knowing that a lack of competence in the use of vital medical equipment could affect other families in a similar way is driving us to raise awareness of the need to ensure proper training and use of equipment to help save the lives of other babies.”

Norfolk boy died from undiagnosed bowel condition after surgery delay

Norfolk Coroner’s Court has issued its conclusions in the tragic case of an eight-year-old boy from Harleston, noting that the gravity of the child’s condition and the need for surgery were not recognised by paediatric staff at the Norfolk & Norwich University Hospital.

The inquest had heard that Charlie Goodwin died at Addenbrooke’s Hospital, Cambridge, on 6 September 2019, following a move from Norfolk & Norwich, where emergency surgery had been conducted hours earlier.

In her written statement for the Coroner, Charlie’s mother, Nicola Goodwin, explained how the happy, football-mad youngest of her six children had been seemingly healthy until a vomiting episode in December 2018 followed by abdominal pains and prolonged loss of appetite.

Early in 2019, Charlie’s abdomen became distended, and the family’s GP shared his mother’s concern about this at a March 2019 consultation. Blood tests ruled out food intolerances, so further investigations began at Norfolk & Norwich University Hospital.

Concerned about worsening abdominal pain and uneaten school lunches, Nicola sought an early hospital appointment, and Charlie was seen at Norwich on 18 July and given an abdominal X-ray. The report showed large bowel dilatation, which Nicola discovered could be due to a blockage.

No follow-up hospital appointment was forthcoming, but on 25 July, Nicola took Charlie to the nurse practitioner because he was feverish with possible symptoms of a urinary infection. The nurse suggested heatstroke as the likely cause.

Symptoms intensified

Over the next few days, Charlie’s symptoms intensified, and a call to NHS111 prompted a visit to the local Beccles Hospital. Checks found nothing wrong, as did a subsequent doctor’s appointment, at which a urine sample was taken and antibiotics prescribed as a precaution.

When Charlie’s temperature hit 40.5oC the next day, and his abdominal pain became severe, Nicola suspected a blockage and took him straight to A&E, where checks for infection were negative and examination by several doctors also found nothing, so he was discharged.

Fever and pain on 2 August led Nicola to take Charlie back to Norfolk & Norwich, where a children’s emergency doctor suspected meningitis, ordering a head scan and lumbar puncture. The radiologist refused a scan, doubting the necessity, but Charlie was admitted later that day.

Overnight on 4 August, the paediatric surgeon was called; he noted Charlie’s distended abdomen and ordered an abdominal X-ray and MRI scan, though the scan never happened, and Nicola was not told why. A heart scan was done and revealed a slight murmur, but no action followed that.

‘Medical mystery’

Inconclusive abdominal ultrasounds were also taken, though Nicola learned weeks later that malrotation meant Charlie’s intestines had not formed properly. Some blood tests but no further scans were carried out before Charlie was discharged on 7 August, described as ‘a medical mystery’.

Pain and lack of appetite continued, and on 14 August, Charlie had a barium swallow test, ordered earlier, which produced a ‘normal’ result but did not cover all of the bowel. A urodynamics test followed for continence issues, which Nicola suspected were linked to the other symptoms.

Charlie returned to school in September but was not eating his packed lunches. On 5 September, he also left his dinner and began vomiting, though with nothing to bring up. A 999 call, prompted by Charlie screaming out in pain and vomiting, brought only an instruction to use her GP or out-of-hours surgery.

Charlie vomited repeatedly and continued to scream, groan and writhe in pain when driven instead to Norfolk & Norwich A&E, which sent him straight to the Children’s Emergency Department. His temperature and blood pressure were very low, and his heart rate was very high. He was put on intravenous fluids, and a surgical review was sought, but the paediatric surgical registrar was already busy.

Despite Charlie’s presentation and a doctor’s request for urgent surgical review at around 22:15hrs, it was not until midnight that the paediatric surgical registrar reviewed Charlie, noting that there was no need for surgical intervention and put forward a plan for conservative treatment. Charlie’s situation worsened throughout the night, several further requests for surgical assessment were made, and hours later, at 2am following escalation to the paediatric surgeon, the surgeon examined Charlie’s enlarged, hard, blue tummy and declared that urgent exploratory surgery was needed as the cause was unclear.

During the preparation for surgery, Nicola exclaimed that Charlie’s pupils were dilated, and a nurse found them unresponsive. Administering oxygen brought a brief reaction, but a doctor sounded the emergency alarm, and Nicola had to leave.

Cardiac arrests

A little later, a nurse came to tell a stunned Nicola that Charlie’s heart had stopped and they were responding to that. Despite two cardiac arrests, the plan for surgery stood, but Nicola was told that her very sick son might not make it.

Charlie went to the theatre at 5 am and an hour later was in recovery, a doctor telling the family he had intestinal malrotation causing a twisted bowel. Later that morning, they were told he would be transferred to the paediatric intensive care unit (PICU) at Addenbrooke’s Hospital.

A third cardiac arrest occurred as Charlie was switched to the children’s ambulance equipment, another while switching at Addenbrooke’s and a fifth after arrival in the PICU. The family were told further CPR would mean no quality of life due to brain damage and multiple organ failure.

At the bedside, the distressed family witnessed blood pouring first from Charlie’s operation wound and then his nostrils. His parents made the agonising decision not to resuscitate him after his next cardiac arrest and were there when he sadly died at 6.20 pm on 6 September.

“There were missed opportunities to give young Charlie Goodwin the timely and appropriate medical treatment that his intestinal malrotation required,” asserts specialist solicitor of Tees Law, acting for the bereaved Goodwin family.

“The final opportunity was at the Norfolk & Norwich University Hospital on that fateful evening in September last year. Prompt and effective emergency surgery could possibly have averted the catastrophic outcome that followed a delay of several hours.”

“The assessment by the paediatric surgical registrar was not acceptable, based on the clinical circumstances,” Tees law explains. “The paediatric surgical registrar did not recognise the severity of Charlie’s illness, and this error delayed the treatment, which could have saved Charlie’s life.

“Following the sad outcome, the hospital’s medical director requested an ‘invited clinical record review’ of the case by the Royal College of Surgeons. The RCS report dated 29 June 2020 formed an important part of evidence for the inquest Coroner.”

NHS Trust accepts RCS findings

The RCS review team investigated various aspects of Charlie’s treatment. Their report made recommendations to address patient safety risks and aspects of the case that pointed to a need for service improvements.

The review team was concerned about the six-hour gap before Charlie was seen by a consultant on the evening of his emergency admission on 5 September 2019. They recommended that: “To facilitate service improvement and reduce the possibility of a similar tragic, catastrophic incident, the Children’s Early Warning Score (CEWS) is reviewed and may be refined by the addition of information from blood gas (lactate) analysis to trigger an automatic senior review escalation.”

Other recommendations for action by the Trust to improve service included undertaking a review of the out-of-hours junior staff cover for paediatric surgery, reassessing the adequacy of facilities for critically ill children in the Children’s Emergency Department at Norwich, and ensuring that information in clinical notes avoids judgmental language and remains factual.

Having received and read the RCS report, on 30 June, the Trust’s medical director sent Charlie’s parents a copy with a letter expressing sincere and heartfelt apologies and condolences and assuring them that the Trust accepted the review conclusions in full and was working hard to address them.

The letter also said, “The key conclusion that stands out to me, and I am sure it will to you also, is that the assessment made of Charlie on 5 September 2019 by the paediatric registrar was not acceptable and that there was a missed opportunity to discuss Charlie’s care in a more urgent manner with the paediatric consultant. The investigation has concluded that had there been a more urgent response, there may have been an opportunity to save Charlie’s life.”

Life could have been saved

This position was reiterated on the Trust’s behalf during the current hearing by the consultant paediatrician, who agreed that the paediatric registrar’s assessment was unacceptable and acknowledged that ‘the level of care we normally provide and that Charlie deserved was not provided that night’.

Under questioning by Counsel, the consultant accepted that the registrar failed to recognise the severity of Charlie’s illness as evidenced by blood gases, delaying by several hours emergency surgery that could have saved his life, particularly if he had been taken to theatre before his first cardiac arrest.

Inquest Conclusions

The Coroner’s conclusions were: “Charlie had a history of abdominal distension and vomiting. He had several admissions to hospital and underwent extensive examinations and tests. He was admitted to Norfolk and Norwich University Hospital on 5 September 2019 presenting as very unwell and in shock. During late 5 September 2019 Charlie was reviewed from a surgical perspective, and the gravity of Charlie’s condition and the need for surgery were not recognised. Surgical advice was not sought from the on-call Consultant.

“Charlie’s condition deteriorated further, and it was not until it was re-escalated to the medical team that the need for surgery was recognised. Charlie did not undergo surgery until the early hours of 6 September 2019, when an emergency laparotomy was performed. Charlie’s condition remained serious. Later that day, he was transferred to Addenbrooke’s Hospital, where his condition continued to deteriorate, and he died. Charlie Goodwin died from a rare and undiagnosed bowel malrotation and midgut volvulus.”

Under her Regulation 28 duty to prevent future deaths, the Coroner has noted that she will write to the General Medical Council, inviting them to have a recording of the inquest and informing them that they may wish to investigate the paediatric surgical registrar’s evidence and fitness to practice.

Having heard the Inquest outcome, Tees Law said, “Had Charlie been assessed properly, it is likely that he would have been taken to surgery much earlier, well before his condition deteriorated further and he suffered from a cardiac arrest. Had that been the case, Charlie’s chances of survival would have been much greater, and it is likely that his life would have been saved.”

Tees Law added, “Charlie’s mum Nicola and the whole family are desperate to ensure this never happens to anyone else. They are devastated by the loss of their wonderful, incredibly loving and funny son and brother. They want to raise general and medical awareness of this rare condition and hope to do so in Charlie’s memory.”

Bright graduate died after GP practice dosage error

West Sussex Assistant Coroner Ms Henderson has concluded an Inquest into the tragic death of a 30-year-old man who had been receiving medication for severe back pain at a village medical practice. It points to shortcomings in the treatment given by the practice in Loxwood.

This week’s hearing and an adjourned hearing at Crawley in January learned that Leeds University graduate Hamish Hardie died in August 2019 at the family home in Wisborough Green from an accidental overdose of prescribed painkillers, for which the dosage label was unclear.

Hamish required pain relief for severe back pain caused by two prolapsed lumbar vertebral discs, for which he was waiting for private surgery, and was dealt with at Loxwood by a qualified doctor who was in his final year of GP training under the supervision of a senior GP.

Dosage not specified

The doctor prescribed two opiate painkillers, Dihydrocodeine and Oramorph, as well as the relaxant Diazepam. The prescription for the Oramorph on the label tragically said it should be taken as directed, which was unclear. Sadly, this was also not identified by the dispensing practitioner within the pharmacy at the practice.

Hamish’s mother Mary-Anne took responsibility for administering the medication, but the uncertainty about the Oramorph label and reliance on Hamish for dosage details meant that more frequent and higher doses were given.

Sadly, Hamish died two days later and a post-mortem confirmed that the primary cause was a prescription drugs overdose, which the Coroner concluded was accidental. The trainee and supervising GPs did not recall seeing an alert on the medical records and the computer system meant that with an Oramorph prescription its labelling default standard was ‘use as directed’.

“We still feel that Hamish was badly let down that day and that his life was unnecessarily cut short by medical failings,” Mary-Anne Hardie reflects. “It was May 2019 when Hamish developed back pain from a suspected slipped disc. That was confirmed on an A&E visit in June, when he was given Diazepam and put on the list for a possible operation. We are disappointed that the GPs did not see the alert on the computer and that if the labelling and prescription advice had been clear, or the pharmacy had spotted the inconsistency, then we feel that Hamish would still be here as he was looking forward to job interviews and a new chapter in his life.”

A ‘perfect storm’

Specialist solicitor Tim Deeming of Tees Law adds: “The Coroner described this as a perfect storm and it is tragic that the GPs did not know that the labelling system defaulted, and that the pharmacy did not then spot this.

“While we are glad to know that the Loxwood Medical Practice has made significant changes to procedures following Hamish’s death we all hope that the NHS and GPs will take steps when providing such prescriptions to provide clear guidance on use, as well as checking computer systems to ensure that other families do not have such devastating outcomes.”

Mother seeks inquest answers over 2016 Corrie McKeague disappearance

The anguished mother of a serviceman who went missing after a night out four years ago hopes that an inquest, which was announced yesterday (5 November) and ordered by the Chief Coroner despite no body being found, will provide answers about what happened to her son.

A painstaking search for 23-year-old Corrie McKeague grabbed national headlines in September 2016 when he failed to return to his base at RAF Honington, Suffolk, after an evening in Bury St Edmunds ten miles away.

CCTV footage last pictured Corrie in a bin area behind some shops in Bury, which led investigators to search a landfill site near Cambridge on two occasions in an unsuccessful quest to establish whether he had been carried off on a waste lorry.

Solicitors instructed

Other investigations and multiple appeals for information about Corrie’s disappearance were inconclusive, but his mother Nicola Urquhart has remained determined to find out what happened and has instructed solicitors to help her press for answers.

“Corrie’s mother wishes to ensure that all the right questions are asked and answered as fully as possible at the inquest scheduled to be undertaken at Ipswich Coroner’s Court early next year,” explains inquest specialist Tees Law.

“The inquest will be an ideal opportunity to bring together the various strands of investigation. Tees Law will support the family throughout what will be an emotional, but we hope fruitful, process for them.

“We shall be doing our utmost to assist the investigation in exploring every aspect of this tragic mystery so that all relevant circumstances are put before the Coroner to enable important conclusions to be drawn.”

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Timely treatment might have saved devoted wife and grandmother

A retired wife and grandmother tragically died in hospital after multiple opportunities were missed to administer appropriate treatment that could have saved her life, an inquest at the Suffolk Coroner’s Court in Ipswich concluded after a two-day hearing.

HM Senior Coroner for Suffolk, Nigel Parsley, heard that 61-year-old grandmother Karen ‘Jane’ Winn from Northwold near Thetford, Norfolk, died at the West Suffolk Hospital in Bury St Edmunds on Monday 15 April 2019, four days after being diagnosed with a suspected urinary tract infection by her GP.

Jane was prescribed antibiotics by her GP on 11 April, but she returned next day as she was by then very unwell. She was referred straight to hospital and admitted the same day. That evening a senior medical consultant diagnosed Jane’s condition as haemolytic anaemia, a serious blood disorder.

Haemolytic anaemia depletes oxygen-carrying red blood cells and medical staff identified that Jane was at risk of developing a deep vein thrombosis, which can result in a life-threatening pulmonary embolism if a blood clot reaches the lungs. So, correct intervention at that point was vital for Jane.

Once the haemolytic anaemia diagnosis had been made, the immediate response should have involved blood transfusions plus ‘prednisolone’ steroids and folic acid. Anticoagulant medication was intended to be given, subject to the result of a repeat blood test to assess internal bleeding risk.

Anticoagulant delayed

Jane initially received only blood transfusions and antibiotics. Not until 14 April were steroids and folic acid administered, whilst no prophylactic anticoagulant was given until 15 April, by which time it was too little, too late to disperse any blood clots that had formed during the previous 72 hours.

An automated venous thromboembolism (VTE) risk assessment warning system is embedded into the electronic patient monitoring for all patients. Disturbingly, this VTE system was manually overridden 58 times between 12 and 15 April, despite Jane’s increased risk of blood clots.

Sadly, soon after transfer to the intensive care unit and an hour after her first and only dose of anticoagulant, Jane suffered a fatal cardiac arrest. This was the outcome that Jane’s distraught husband Brian and the wider family had feared and one they believe could have been avoided.

“We are bitterly upset that such an essential part of the treatment available for Jane’s illness wasn’t used promptly,” says a close family member. “The right diagnosis was made, but life-saving medication was given too late, despite repeated reminders. Our hope now is that lessons learned will prevent the same thing happening to anyone else.”

Significant blood clots

The primary cause of death, a bilateral pulmonary embolism, with deep venous thrombosis and haemolytic anaemia as contributory causes, was confirmed at post-mortem. Widespread pulmonary emboli in the lungs and significant blood clots in veins of the upper leg were both evident.

In summary, the Coroner concluded that Jane’s death resulted from the progression of a naturally occurring illness, contributed to by the non-administration of medication to prevent blood clots despite being earlier identified as essential for her treatment; the latter amounted to neglect.

Tees Law, acting for the bereaved family, comments: “A venous thromboembolism risk assessment is mandatory for all patients admitted to hospital and should be completed within hours of admission. It was wholly unacceptable for the assessment alert to have been overridden 58 times over those four days. The Coroner’s finding of neglect acknowledges the total failure to give Jane basic medical treatment that would ultimately have increased her chances of survival.”

Read the full story here.

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