Source · Prevention of Future Deaths
Sheila Creegan
Ref: 2026-0147
Date: 10 Mar 2026
Coroner: Graeme Irvine
Area: East London
Responses identified: 0 / 2
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The Trust failed to conduct a proper patient safety investigation into the death despite clear errors, including an inaccurate initial cause of death and missed diagnoses of infection and heart failure.
Date
10 Mar 2026
56-day deadline
5 May 2026 est.
Responses identified
0 of 2
Coroner's concerns
The Trust failed to conduct a proper patient safety investigation into the death despite clear errors, including an inaccurate initial cause of death and missed diagnoses of infection and heart failure.
View full coroner's concerns
1. BHRUT chose not to investigate this case as part of NHS England’s Patient Safety Framework. Mrs Creegan’s death ought to have been subject to such an investigation.
Decisions were reached at two clinical governance meetings that meaningful learning could not flow from a governance investigation into the circumstances of Mrs Creegan’s care. Such decisions appear to be incongruous with;
a. The inaccurate cause of death initially offered by the Trust,
b. The failure to investigate the seat of Mrs Creegan’s burgeoning infection after her pneumonia resolved,
c. The missed diagnosis of infective endocarditis,
d. The failure to monitor the development of Mrs Creegan’s heart failure during her inpatient treatment.
Decisions were reached at two clinical governance meetings that meaningful learning could not flow from a governance investigation into the circumstances of Mrs Creegan’s care. Such decisions appear to be incongruous with;
a. The inaccurate cause of death initially offered by the Trust,
b. The failure to investigate the seat of Mrs Creegan’s burgeoning infection after her pneumonia resolved,
c. The missed diagnosis of infective endocarditis,
d. The failure to monitor the development of Mrs Creegan’s heart failure during her inpatient treatment.
Report sections
Investigation and inquest
On 26th March 2025, this court commenced an investigation into the death of Sheila Creegan aged 81 years. The investigation concluded at the end of the inquest on 10th March 2026. #
The inquest concluded with a Narrative conclusion,
“Sheila Creegan died on 17th March 2025 due to infective endocarditis, a condition that was neither treated, nor diagnosed during her final, 14 day admission to hospital. Mrs Creegan's endocarditis was caused by bacteria entering her bloodstream as a consequence of abdominal surgery undertaken in February 2025. The bacteria lodged and multiplied upon calcified nodules on Mrs Creegan's mitral valve, a symptom of chronic cardiac illness. The bacterial vegetation on the valve caused haemorrhage which, in turn caused a cardiac arrest.”
Sheila Creegan’s medical cause of death was determined as;
1a Bacterial Endocarditis 1b Subacute Intestinal Obstruction (operated on) 1c Peritoneal Adhesions (previous appendicectomy and cholecystectomy) II Ischaemic and Hypertensive Heart Disease
The inquest concluded with a Narrative conclusion,
“Sheila Creegan died on 17th March 2025 due to infective endocarditis, a condition that was neither treated, nor diagnosed during her final, 14 day admission to hospital. Mrs Creegan's endocarditis was caused by bacteria entering her bloodstream as a consequence of abdominal surgery undertaken in February 2025. The bacteria lodged and multiplied upon calcified nodules on Mrs Creegan's mitral valve, a symptom of chronic cardiac illness. The bacterial vegetation on the valve caused haemorrhage which, in turn caused a cardiac arrest.”
Sheila Creegan’s medical cause of death was determined as;
1a Bacterial Endocarditis 1b Subacute Intestinal Obstruction (operated on) 1c Peritoneal Adhesions (previous appendicectomy and cholecystectomy) II Ischaemic and Hypertensive Heart Disease
Circumstances of the death
Mrs Creegan was an 81-year-old woman with extensive comorbidity including heart failure. Sheila underwent emergency abdominal surgery on 5th February 2025 for adhesiolysis. The surgery was uneventful, but Mrs Creegan’s post-surgical recovery was complicated leading to delayed discharge from hospital on 27th February 2025.
On 3rd March 2025 Mrs Creegan was admitted to hospital by ambulance with difficulty in breathing, anaemia and a suspected GI bleed. Mrs Creegan was treated for pneumonia and fluid overload. A blood transfusion was administered. Imaging investigations found no haemorrhage or significant abdominal complication of surgery.
By 14th March 2025 the trust determined that the chest infection had resolved, despite that, Mrs Creegan’s infection markers continued to climb, and her National Early warning Score (NEWS) deteriorated.
Neither a septic screen nor an echocardiogram was undertaken (having previously been requested).
Mrs Creegan died in hospital on 17th March 2025 which both the attending physician and medical examiner offering a cause of death incorporating pneumonia as the primary, direct cause of death. An autopsy found no sign of extant pneumonia at the time of death and identified bacterial vegetations on the chronically calcified leaflets of the mitral valve in the heart as the primary cause of death.
On 3rd March 2025 Mrs Creegan was admitted to hospital by ambulance with difficulty in breathing, anaemia and a suspected GI bleed. Mrs Creegan was treated for pneumonia and fluid overload. A blood transfusion was administered. Imaging investigations found no haemorrhage or significant abdominal complication of surgery.
By 14th March 2025 the trust determined that the chest infection had resolved, despite that, Mrs Creegan’s infection markers continued to climb, and her National Early warning Score (NEWS) deteriorated.
Neither a septic screen nor an echocardiogram was undertaken (having previously been requested).
Mrs Creegan died in hospital on 17th March 2025 which both the attending physician and medical examiner offering a cause of death incorporating pneumonia as the primary, direct cause of death. An autopsy found no sign of extant pneumonia at the time of death and identified bacterial vegetations on the chronically calcified leaflets of the mitral valve in the heart as the primary cause of death.
Copies sent to
of Mrs Creegan, to the Care Quality Commission, and to the local Director of Public Health
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Report details
- Reference
- 2026-0147
- Date of report
- 10 March 2026
- Coroner
- Graeme Irvine
- Coroner area
- East London
Responses identified
Responses identified
0 of 2
2 responses not yet linked
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 5 May 2026 (estimated).
Sent to
- Barking, Havering and Redbridge University Hospitals NHS Trust
- Department of Health and Social Care