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23 hours ago
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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.
Graeme Irvine, the senior coroner for east London, 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 said there was a “risk that future deaths could occur unless action is taken”.
Every, 27, from Dagenham in east London, had learning disabilities and a muscle-wasting condition called myotonic dystrophy (MD). She 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 MD – and suffered a cardiac arrest on 8 May.
She was later moved into a general ward where she died on 14 May in a state of “agitation and pain”, her family told her inquest in October 2024.
A review by the NHS trust referred the case to the coroner in 2019, advising the cause of death was advanced cancer and 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 when Every 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.
Irvine said the inquest had been “prejudiced by the absence of contemporary nursing and medical notes from various stages” of Every’s treatment.
He also said “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 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.
Irvine said during the inquest nursing staff were “incapable” of explaining the “appropriate criteria” needed before starting CPR on an unresponsive patient.
He added: “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 had “taken the issues identified by the learned coroner very seriously and has taken positive action to address those issues”, including mandatory staff training to raise awareness of the adjustments needed to care for patients with learning disabilities and sessions to stress “the importance of good record-keeping”.
The trust said a shortage of nurses with the specialist learning disability skills had hampered recruitment efforts and meant it had not ensured qualified nurses for patients with learning disabilities were working on weekends and during holiday periods.
It accepted that an initial investigation “found care and service delivery problems but did not identify that any of these contributed” to 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.
