Wes Streeting to respond to Chloe Every Preventing Future Deaths warning from coroner
As reported by the Guardian and other news platforms, the coroner investigating the death of 27-year-old Chloe Every at Queen's hospital, Romford, has issued a preventing future deaths warning against the Barking, Havering and Redbridge university hospitals NHS trust.
The PFD report has been sent to the chief coroner, the Care Quality Commission and the secretary of state. Graeme Irvine, senior coroner for east London, also sent his report to health secretary Wes Streeting, who has 40 days to respond.
Enquiries to the Department of Health about their response suggest they are waiting for input from their learning disability team.
Mr Irvine had previously concluded that ‘gross failures’ in the care of Chloe by the hospital may have led to her death in 2019. He said evidence at the inquest was concerning and that there was a 'risk that future deaths could occur unless action is taken'.
Caron Heyes represented Chloe's family in their fight to have her death properly investigated after the trust initially informed the coroner that Chloe had died from natural causes - Advanced Bowel Cancer, contributed to by the underlying condition of Myotonic Dystrophy (MD) - and that her death did not merit an inquest.
Chloe, who had learning disabilities, was wrongly prescribed morphine by medics, despite it being known to cause respiratory problems for people with MD.
The inquest also revealed the absence of specialist learning disability nurses to assist Chloe in communicating with staff and the administration of an enema when she was unable to consent.
Mr Irvine said the inquest had been “prejudiced by the absence of contemporary nursing and medical notes from various stages” of Chloe's treatment and that the staff involved could not be identified because of lapses in records.
The regularity of Chloe’s clinical observations “fell well below the expected level” and included more than 10 hours in which no observations were undertaken.
“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 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.
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