Source · Prevention of Future Deaths
Raquel Harper
Ref: 2023-0192
Date: 13 Jun 2023
Coroner: Nadia Persaud
Area: East London
Responses identified: 0 / 1
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Inadequate history taking led to incorrect assumptions, nursing staff failed to follow NEWS policy for escalation, and there was confusion and non-compliance with the PE policy, highlighting a need for review.
Date
13 Jun 2023
56-day deadline
7 Aug 2023
Responses identified
0 of 1
Coroner's concerns
Inadequate history taking led to incorrect assumptions, nursing staff failed to follow NEWS policy for escalation, and there was confusion and non-compliance with the PE policy, highlighting a need for review.
View full coroner's concerns
1. There was a lack of thorough history taking and a number of assumptions were made on the basis of Raquel’s high BMI. There was an assumed chronic low oxygen saturation with no evidence that the doctors had checked the records available or asked the patient about her baseline. The oxygen saturations recorded in the Barts sleep apnoea clinic in 2015 and 2016 were noted to be 99% and 100%.
2. There was a lack of escalation of monitoring following the NEWS score of 10. It is of concern that the NEWS policy was not complied with by the nursing staff.
3. There was disagreement between senior clinicians as to how the Trust’s PE policy should have been applied. The policy is often not used in accordance with the specific wording. For example, the requirement for pleuritic chest pain is often ignored in practice. A senior clinician within the Trust considered that the caveat for pleuritic chest pain in the policy should be reviewed. In addition, the senior clinician described some of the wording in the policy as “clumsy”. In light of this, the Trust may wish to review the policy.
2. There was a lack of escalation of monitoring following the NEWS score of 10. It is of concern that the NEWS policy was not complied with by the nursing staff.
3. There was disagreement between senior clinicians as to how the Trust’s PE policy should have been applied. The policy is often not used in accordance with the specific wording. For example, the requirement for pleuritic chest pain is often ignored in practice. A senior clinician within the Trust considered that the caveat for pleuritic chest pain in the policy should be reviewed. In addition, the senior clinician described some of the wording in the policy as “clumsy”. In light of this, the Trust may wish to review the policy.
Report sections
Investigation and inquest
On the 26th July 2021 I commenced an investigation into the death of Raquel Mellonie Harper, aged 33 years. The investigation concluded at the end of the inquest on 2nd May 2023. The conclusion of the inquest was a narrative conclusion:
Raquel Harper died as a result of natural causes. Her death was however contributed to by an omission of hospital staff to carry out appropriate investigations and to instigate timely treatment for her pulmonary embolism.
Raquel Harper died as a result of natural causes. Her death was however contributed to by an omission of hospital staff to carry out appropriate investigations and to instigate timely treatment for her pulmonary embolism.
Circumstances of the death
Raquel Harper attended Whipps Cross Hospital on the 23 June 2021. She complained of a 5-day history of shortness of breath and difficulty breathing. Raquel had a low oxygen saturation, a high respiratory rate and a tachycardia. The assessing doctor used the pulmonary embolism rule out criteria (PERC), to rule out the likelihood of a pulmonary embolism causing her symptoms. The PERC test was positive, and a D Dimer should have been carried out. This was not done. A diagnosis of iron deficiency anaemia was made, based upon a low haemoglobin and low MCV level. Raquel was admitted to hospital and suffered from periods of desaturation requiring medical review and assessment. The diagnosis of iron deficiency anaemia was not re-visited and further investigations, such as arterial blood gases were not carried out. In the very early hours of 25 June 2021, Raquel became critically unwell. She required escalation of her care, but this was not provided until she was in a peri-arrest state at around 0330 on 25 June 2021. Raquel suffered a cardiac arrest at around 0400 and received resuscitation and thrombolysis. Sadly, there was no response to the emergency efforts and Raquel passed away at Whipps Cross Hospital on 25 June 2021. Had Raquel received the D Dimer test on the 23 June 2021, in accordance with the Trust's policy, this is likely to have triggered further investigations which would have resulted in a diagnosis of pulmonary embolism and a treatment dose of lower molecular weight heparin. On the balance of probabilities this would have prevented Raquel's death on the 25 June 2021.
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Report details
- Reference
- 2023-0192
- Date of report
- 13 June 2023
- Coroner
- Nadia Persaud
- Coroner area
- East London
Responses identified
Responses identified
0 of 1
1 response not yet linked
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 7 Aug 2023.
Sent to
- Barts Health NHS Foundation Trust