“The London Ambulance Service (LAS) emergency operations centre (EOC) made a pre hospital…”
Dated 31 Jul 2019, from the coroner for Inner North London. Sent to 2 organisations or people.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
Report put online after its 56 daysOrganisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk; a reply may have been sent and not yet published.
judiciary.uk put this report online on 18 Oct 2019, after the 56 days for replies had ended (25 Sep 2019). These dates can’t tell us whether a reply was due before it went online. A reply may have been sent and not yet published.
- Report dated31 Jul 2019
- Deadline25 Sep 2019
- Published on judiciary.uk18 Oct 2019
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| London Ambulance Service NHS Trust | Report put online after its 56 daysNo response published on judiciary.uk. judiciary.uk put this report online on 18 Oct 2019, after the 56 days for replies had ended (25 Sep 2019). These dates can’t tell us whether a reply was due before it went online. |
| Whittington Health NHS Trust | Report put online after its 56 daysNo response published on judiciary.uk. judiciary.uk put this report online on 18 Oct 2019, after the 56 days for replies had ended (25 Sep 2019). These dates can’t tell us whether a reply was due before it went online. |
The coroner’s concerns
This report was published as a scan, so its text was read automatically. Check the wording against the original before you quote it.
1. The London Ambulance Service (LAS) emergency operations centre (EOC) made a pre hospital alert telephone call to the Whittington Hospital emergency department, regarding: the expected arrival eight minutes later of a patient in respiratory arrest. This was good practice. However, they failed to include in that alert the information that Ms Choya was pregnant. This was a crucial detail, which had been passed to the LAS at the very outset by her husband, and then again to the EOC by the emergency medical crew on scene. 2. On arrival at the Whittington Hospital, the detail of the pregnancy was not communicated effectively. It is unclear whether the LAS crew did not mention the fact, or whether the emergency staff simply did not hear it. In any event, it took 16 minutes post arrival for the pregnancy to be recognised and the obstetric team to be called. 3. Without the obstetric team, the emergency department team focus was on the potential for a pulmonary embolism, and alteplase was given. Only later was a scan conducted and free fluid noted. By the time of the laparotomy it was too late to save Ms Choya.
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, 2019-0281
- Added to Minute Book
- 8 Oct 2026
- Reuse
- We show short extracts and link to the original. We don’t host the full report.
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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
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