“Mulu underwent surgery to remove a giant pituitary tumour on 24 January 2025”

The coroner’s concerns

Mulu underwent surgery to remove a giant pituitary tumour on 24 January 2025. She was discharged home on 27 January with hydrocortisone for low cortisol levels. She was given discharge / safety netting / red flag advice, both orally and in writing, which advised her to seek medical help immediately if she vomited more than once. Following discharge, Mulu suffered intermittent vomiting. Her son called the NHS 111 service on 31 January at 16:00 hours. He reported that Mulu had undergone brain surgery and had been vomiting for 48 hours. The outcome of the call was for Mulu to speak to a clinician in a local service within 2 hours. I heard evidence that neurosurgery is not a specified Pathways category, nor is it part of the “vomiting” algorithm. The Call Handler on 31 January 2025 erroneously recorded Mulu’s surgery as a “head injury” which resulted in it receiving a higher priority outcome than it otherwise would have done. An ANP called Mulu back at 16:57. They took an account that Mulu had undergone surgery to remove a pituitary tumour a week previously and that she had been vomiting since the previous day, that she vomited when she ate food but that she was drinking well. The disposition reached was “home management”, this being that she was to ensure that she remained well hydrated and to eat in small amounts. They advised that if she was unable to keep fluids down and had symptoms of dehydration, she would need to be seen in A&E. Again, there was no prompt in relation to brain surgery or for questions about any discharge advice. At 09:37 on 1 February, Mulu’s son again called 111 reporting that she had deteriorated. As he was not with Mulu, no assessment was conducted but advice was given repeatedly that Mulu could attend hospital or contact 111 directly if she remained unwell. At 11:21 on 1 February 2025 Mulu was found unresponsive and an ambulance was called. Paramedics arrived at 11:40 and found Mulu in cardiac arrest. It is likely that Mulu suffered a seizure, followed by cardiac arrest, due to hyponatraemia. Neither the 111 nor Clinical Assessment Service asked Mulu whether the hospital had given her any post-surgical discharge, worsening or red flag worsening advice. Had they done so, this may have prompted Mulu to review the written discharge advice she had been given. That advice was that vomiting was a safety alert; that repeated vomiting required immediate medical help; that any concerning symptoms required medical attention from a GP, A&E or UCLH directly and that for persistent vomiting, advice on hydrocortisone should be sought from 111, 999 or A&E. 1. LAS informed me that they have advised Pathways of Mulu’s case and recommended that Neurosurgery be added to the supporting information for “head injury” and “vomiting” algorithms. I do not know if Pathways have, or have agreed to, action this or what the timescales are. 2. I am concerned that without a dedicated pathway for “neurosurgery”, it is left to call handlers to choose the most appropriate pathway. To me, “head injury” is not reflective of elective, non-trauma surgery. 3. Pathways does not include a question for post-discharge surgery patients about whether they have been given discharge, worsening or red flag advice by their surgical team. 10. COPIES AND PUBLICATION OF THIS REPORT I have a duty to send a copy of my report to every Interested Person who in my opinion should receive it. I also may send a copy of the report to any other person who I believe may find it useful or of interest. I can confirm I have sent the report to: 1. Mulu’s family 2. University College London Hospitals NHS FT 3. Royal Free London NHS FT 4. London Ambulance Service NHS FT 5. London Central & West Unscheduled Care Collaborative I also have a duty to send a copy of the report to the Chief Coroner. You may make representations to me, the coroner, about the publication of the contents of this report in line with Chief Coroner’s PFD Publication Policy (2026). Any representations will be sent to the Chief Coroner alongside the report. Please refer to box 4 above for additional information relating to the publication of reports and responses. SIGNATURE

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source

judiciary.uk, Prevention of Future Deaths reports, 2026-0316

Added to Minute Book

8 Oct 2026

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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0