Michelle Dawes

On 18/7/25, I commenced an investigation into the death of Michelle DAWES, aged 55 years. 

The medical cause of death was Cause of death 1a Respiratory failure  Cause of death 1b Granulomatous inflammatory disease How, when and where

Mrs Dawes was a 55 year old female who presented to hospital on 3 June  2025, the working diagnosis at that time was community acquired pneumonia.  She was discharged with antibiotics and a plan to have a repeat chest x-ray in six weeks. On 8 July 2025 she represented to hospital with worsening  symptoms. A chest x-ray revealed a large right sided pleural effusion, she was treated with intravenous antibiotics and a plan was formed to move her to a  respiratory ward to insert a chest drain. There was a delay moving Mrs Dawes to the respiratory ward, during that time Mrs Dawes deteriorated. She was  transferred to the respiratory ward on 12 July 2025. A chest drain was not  inserted and Mrs Dawes went on to suffer a cardiac arrest and died on 14 July 2026 at Walsall Manor Hospital. 

Conclusion at inquest Mrs Dawes died from respiratory failure, it is unlikely that she would have died  when she did had a chest drain been inserted during the seven days she spent in hospital prior to death.

Mrs Dawes presented to hospital on 3 June 2025. The working diagnosis of the hospital at that time was Community Acquired Pneumonia, Mrs Dawes was discharged with antibiotics and a plan to have a repeat x-ray in six weeks time. The treatment received and discharge and plan formed as a result of that  hospital attendance was appropriate.  

Mrs Dawes represented to hospital on 8 July 2025 with worsening symptoms  including shortness of breath, lethargy and weight loss. A chest x-ray revealed a large right sided pleural effusion, Mrs Dawes also had raised inflammatory   markers. She was treated with antibiotics and the plan was to move her to the respiratory ward where she could have a chest drain inserted.  

For reasons unknown Mrs Dawes was not moved to the respiratory ward, her  move was delayed. She began to deteriorate, with acute kidney injury and  deranged liver function noted before she was moved to the respiratory ward on Saturday 12 July 2025. 

On 12 July 2025 Mrs Dawes was reviewed on the respiratory ward and it was  noted that she had a raised INR level which could increase the risk of her  bleeding during the chest drain insertion. A plan was therefore formed to give  Mrs Dawes vitamin K to decrease her INR and to insert the chest drain after  the weekend. Evidence was heard at inquest to confirm INR levels should have been checked on 8 July 2025 when the plan was initially formed to insert  chest drains. Had that check been done, Mrs Dawes’ higher than appropriate  INR would have been identified at that time and treated before she was moved to the respiratory ward, likely allowing the chest drain to be inserted on any  date from 10 July 2025 onwards.  

During the weekend Mrs Dawes continued to deteriorate, she was reviewed on several occasions by resident Doctors but was not escalated up for Consultant  input. The decision made during the weekend was that Mrs Dawes was stable  and therefore the INR level was to be reduced with vitamin K before inserting  the chest drain after the weekend.  

Mrs Dawes suffered a cardiac arrest on Monday 14 July 2025 and died.

A chest drain was never inserted.

The hospital Trust have identified learning as a result of Mrs Dawe’s death,  however, implementation of the changes required has not been fully undertaken.

In my opinion unless action is taken to address the above concerns then there is a significant risk of future deaths and I believe each of you have the power to take such action.