A coroner who ruled that “gross failure” in the hospital care of a disabled woman “possibly contributed to her death” has called for improvements to protect patients.
Senior coroner for east London Graeme Irvine said the inquest into the death of Chloe Every had revealed matters “giving rise to concern” while she was in the care of Barking, Havering and Redbridge University Hospitals NHS Trust.
He feared there “is a risk that future deaths could occur unless action is taken”.
Ms Every, 27, of Dagenham, east London, who had learning difficulties and a muscle-wasting condition, was admitted to Queen’s Hospital in Romford in April 2019 where a scan revealed possible signs of bowel cancer.
She was prescribed morphine – despite it posing a risk to people with her muscle condition – and suffered a cardiac arrest on May 8.
She was later moved into a general ward where she died on May 14 2019, in a state of “agitation and pain”, her family told her inquest in October this year.
An initial review by the NHS trust subsequently referred the case to the coroner in 2019, advising the cause of death was advanced cancer and myotonic dystrophy (MD).
The inquest revealed “failures” in the care she received in hospital – including the prescription of morphine, which can cause respiratory problems for people with MD, the absence of specialist learning disability nurses to assist her in communicating with staff, and the administration of an enema to Ms Every when she was unable to consent.
She was “unconscious before, during and after the procedure, it is possible this procedure contributed to her death”, the coroner said in his prevention of future deaths (PFD) report.
The report has been sent to the chief coroner, the Care Quality Commission and the local director of public health.
The coroner said the inquest had been “prejudiced by the absence of contemporary nursing and medical notes from various stages” of Ms Every’s treatment.
He also stated “the extent of these lapses meant staff who made important treatment decisions could not be identified, and where staff could be identified, no contemporary account of their rationale for making treatment decisions could be located”.
The regularity of Ms Every’s clinical observations “fell well below the expected level” and included a period of more than 10 hours in which no observations were undertaken.
The coroner recalled that during the inquest nursing staff were “incapable” of explaining the “appropriate criteria” needed before starting CPR on an unresponsive patient.
He also stated: “A serious incident report completed by the trust in the second half of 2019 failed to identify a series of healthcare failings in Chloe’s treatment.
“Management failings at the trust meant that Chloe’s death was not reported to a coroner until August 2023, by which time Chloe’s body had been cremated, denying the court an opportunity to gather relevant evidence through autopsy.”
In its PFD response, the trust said it has “taken the issues identified by the learned coroner very seriously and has taken positive action to address those issues”.
The trust did not ensure qualified nurses for learning disability patients were working on weekends and holiday periods.
A shortage of nurses with the specialist learning disability skills had hampered recruitment efforts, according to the trust.
It has introduced mandatory staff training to try to raise awareness of the adjustments needed to care for these patients.
Training sessions are being run to stress “the importance of good record-keeping” by the trust, which uses both electronic and paper records as it works towards a “more integrated system”.
An online audit tool is also being tested to help improve the use of data.
More training is to be held about informed consent in line with legal and regulatory requirements.
Annual resuscitation courses, designed to suit different roles, also have to be completed by all staff.
There is also more training relating to the identification and escalation of acutely deteriorating patients for the nurses who care for them.
The trust said it is looking at its procedures and audits to ensure that relevant personnel receive emergency calls.
Since September 2024, all deaths are reviewed by the Medical Examiner Office.
It means that a proposed cause of death can be looked into and the bereaved get a chance to air any concerns about the standard of care.
It can also help provide medical advice for the local coroner.
The trust accepted that an initial investigation “found care and service delivery problems but did not identify that any of these contributed” to Ms Every’s death.
It added: “It did not explore the cause of Chloe’s cardiac arrest nor the prescribing of morphine, cornerstones of the family’s complaints.
“Due to how significantly unwell Chloe was during this admission, it was not felt that the cardiac arrest was unexpected, which may have impacted on the lack of focus on this within the initial investigation.”
An improvement oversight panel is in place to look at the handling of patient safety incidents before they are closed.
