Coroner seeks improvements after care failings ‘possibly contributed’ to death
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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. Senior coroner for east London Graeme Irvine 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 feared there “is a risk that future deaths could occur unless action is taken”. Ms Every, 27, of Dagenham, east London, who had learning difficulties and a muscle-wasting condition, 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 her muscle condition – and suffered a 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 her inquest in October this year.
An initial review by the NHS trust subsequently referred the case to the coroner in 2019, advising the cause of death was advanced cancer and myotonic dystrophy (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 to Ms Every when she was unable to consent.
