A coroner has ruled that “gross failure” in the hospital care of a disabled woman “possibly contributed to her death”.
Chloe Every had learning difficulties and a muscle-wasting condition and was admitted to Queen’s Hospital in Romford in April 2019 where a scan revealed possible signs of bowel cancer.
The 27-year-old patient was prescribed morphine – despite it posing a risk to people with her muscle condition – and suffered a first 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 an inquest last week.
An initial review by the Barking, Havering and Redbridge University Hospitals NHS Trust subsequently referred the case to the coroner in 2019, advising that the cause of death was advanced cancer and myotonic dystrophy (MD).
But the inquest into Ms Every’s death 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 seemingly asleep and unable to consent.
Senior coroner for East London Graeme Irvine, delivering his conclusion at East London Coroner’s Court on Monday, said these failures “possibly contributed to her death”.
“The inquest concluded that multiple actions and omissions of hospital staff during Chloe’s inpatient admission did not comply with local and national guidance”, Mr Irvine told the court in Walthamstow.
“Each of these actions taken alone would not necessarily amount to a gross failure.
“But taken together, the failures in care do amount to gross failure.
“We have the absence of any evidence to justify the prescription of morphine; the significant and frequently observed laxes in the observation of vulnerable patients; and the absence of anything approaching consent for what is a very invasive and intimate procedure.”
Ms Every’s death was caused by complications of a cardiac arrest the coroner said was “probably” contributed to by the morphine given to Ms Every in treatment for bowel cancer.
A post-mortem examination of Ms Every’s body was not held.
Ms Every’s aunt, Lisa Every, had previously told the inquest her niece was also given an enema while she was “still sleeping” on the same day she suffered her first cardiac arrest.
Nurse Asia Bawah, who carried out the procedure, had told the court that she felt Ms Every had “consented non-verbally”.
But Mr Irvine said on Monday the evidence showed hospital staff “haven’t got a clue at how appropriate consent procedures should be undertaken”.
The coroner also criticised the lack of “clear and contemporary records” of Ms Every’s care by the Trust’s doctors and nurses, which meant he was unable to apply the legal test for neglect and determine whether or not there was a “clear causation” between the identified failures and Ms Every’s death.
“Had the doctors of the Trust done what they were supposed to do under the GMC guidance, I would have been in a far better position to determine whether the prescription of morphine was justified,” Mr Irvine told the court.
“Had the nursing staff provided clear and contemporary records of their decision-making in relation to the treatment of Chloe, it’s entirely possible that I would have been able to consider expert pathological evidence that could assist me in understanding the mechanism of Chloe’s death.”
He added: “I am concerned these are actions and events that did not take place in isolation.”
Mr Irvine ordered for a Regulation 28 Prevention of Future Deaths report to be sent to the Trust – as well as to the Secretary of State for Health and Social Care, and Quality Care Commission (CQC).
Ms Every’s aunt Lisa Every said in a statement: “I cannot forgive or forget that Chloe died after terrible care that marred her last days which should have been spent in peace with her family, and that the Trust deliberately told the coroner that she died of cancer and myotonic dystrophy.
“If I had not persisted in forcing through an independent Level 3 investigation, the role of the cardiac arrest in causing her death would never have come out and this inquest would never have been heard.”
And Caron Heyes, a solicitor on behalf of Ms Every’s family, said: “So many aspects of Chloe’s care heard this week raise serious patient safety issues, including failures regarding consent and best interest processes, vital where patients have learning disabilities.
“Because the Trust failed to properly investigate Chloe’s death, it has taken more than four years for the coroner to hear her case.
“It is shocking. Families should not have to force hospitals to properly investigate their errors.”
The BHR University Hospitals NHS Trust will have 56 working days to respond to the issues raised in the coroner’s report.
Matthew Trainer, chief executive of the Trust, said in a statement: “We are extremely sorry Chloe did not receive the care she should have in our hospital.
“We’d also like to apologise to her family for the distress caused by our initial investigation into her death, which was not thorough enough.
“We hope it provides some small comfort that since her death in 2019 we have taken steps to improve care for patients with learning disabilities.”