‘Gross failures’ in London hospital’s care may have led to disabled woman’s death
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Coroner calls for improvements after Chloe Every was wrongly prescribed morphine shortly before she died. 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 andMD.
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 she was unable to consent.
