Coroner opens inquest examining treatment of woman with learning disability at Queen’s Hospital, Romford

Ms Every, 27, died in May 2019 at Queen's Hospital, Romford. Barking, Havering and Redbridge Hospital Trust initially informed the coroner that Ms Every died from natural causes – Advanced Bowel Cancer, contributed to by the underlying condition of Myotonic Dystrophy - and that her death did not merit an inquest.

A root cause report completed later in 2019, however, identified serious failings in her care, specifically the administration of high doses of morphine to someone with myotonic dystrophy and that she suffered cardiac arrest during an enema.

The family complained to the CCG (Clinical Commissioning Group, now the Integrated Care Board) about the inadequacies of the investigation and a Level 3 Serious Untoward Investigation was then commissioned. This also identified serious failings in the care and in the previous investigation process. 

After long campaigning for a re-review by the family, Area Coroner Mr Graeme Irvine was so concerned that he sought permission to reopen the inquest from the Chief Coroner Judge Teague.

In his opening remarks today, Mr Irvine severely criticised the governance of the Trust for failing to refer Ms Every's death for inquest and set out the serious errors in her care.

Chloe's story

Chloe had learning disabilities and myotonic dystrophy. In the two years before her death, she had multiple health appointments following reports of increased tiredness and neck lesions. She also had blood tests that began to identify her bowel cancer in February 2019, but there were delays in recognising their significance. 

A CT scan at Princess Royal at the end of April 2019 after she was admitted with significant abdominal pain showed she had advanced bowel cancer. She was readmitted the next day and booked for a flexible sigmoidoscopy to take a biopsy. While waiting for the biopsy procedure she was nursed on a side room on the Medical Assessment Unit in contravention of the Trust's policies, without a pain management programme in place.  She was in significant pain.

Chloe was never assigned to a consultant and no treatment path was created for her. No pain management plan was put in place.  Crucially, her long-standing neurologist was not told of her admission, nor were they consulted on the interaction of her underlying MD condition with the plan for investigating the cancer and use of morphine and anti-nausea medication.  She was also not admitted under the NHS Trust’s learning disability admission pathway.

Without the input of consultant-led multi-disciplinary care, accommodating her learning disability needs, the decision was made by the medical team that she was to have a sigmoidoscopy, so a biopsy could be taken to confirm the diagnosis. 

Increasing amounts of morphine were being given in the lead up to the procedure. Without appreciation for any risks associated with giving morphine to patients with MD. The Trust has since altered its prescribing model.

 On the morning of the sigmoidoscopy, nursing staff recorded she had an irregular heartbeat at around 4am and a drop in blood pressure but no doctors were notified. Her NEWS score rose to 4.

The attending nurse gave her an enema to prepare her for the sigmoidoscopy at 7am, during which Chloe went into cardiac arrest. Ater six rounds of CPR, Chloe became responsive and was moved to a high dependency ward. She stabilised over the following days.

Three days later, she was moved to a regular nursing ward, placed in a side ward and moved to occasional monitoring. Chloe’s aunt, who had barely left her side since her admission, was advised to go home for a rest since Chloe’s condition was stable.

A few hours later, Chloe was found unconscious and unresponsive and due to a DNR, was not resuscitated. She died shortly afterwards.

There was no mention in the Trust's original statement to the coroner of the cardiac arrests, nor missed observation and management of the irregular heartbeat and abnormal blood pressure just prior to the first arrest.

The Trust did not recognise as failures their handling of Chloe’s admission or non-involvement of her neurologist in her care. Unsurprisingly, the Coroner initially determined there would be no Inquest.

The Hospital Trust conducted a level 2 Serious Incident inquiry in response to the family’s complaints about Chloe’s care. This investigation failed to explore the causes of Chloe’s cardiac arrest, in addition to overlooking the impact of the morphine prescription and was an inadequate exploration of the care leading up to Chloe’s death by the hospital Trust.

Fieldfisher represents the family of Chloe Every as part of our ongoing partnership with Mencap, running the Rachel's Voice programme, providing pro bono advice and representation to families who have suffered the loss of loved ones with a learning disability in an Acute Hospital setting, as part of an ongoing campaign to reduce healthcare inequality for patients with a learning disability. 

Advocacy at the hearing is provided pro bono by Jo Moore of 1 Crown Office Chambers.

Chloe’s case was part of BBC Panorama: Will the NHS Care For Me? which aired in October 2022.