“Ms Nakafeero was assessed at a Gynae-oncology clinic in early 2019”
Dated 24 Jul 2023, from the coroner for East London. Sent to 3 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
Deadline passedReplies were due by 18 Sep 2023. A reply may have been sent and not yet published.
Organisations 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.
- Report dated24 Jul 2023
- Deadline18 Sep 2023
- Published on judiciary.uk28 Jul 2023
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Barts Health NHS TrustNamed in the report as “Barts Health NHS Foundation Trust” | Response publishedPublished on judiciary.uk in July 2023. |
| NHS England | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 18 Sep 2023. A reply may have been sent and not yet published. |
| Department of Health and Social Care | Response publishedPublished on judiciary.uk in July 2023. |
The coroner’s concerns
1. Ms Nakafeero was assessed at a Gynae-oncology clinic in early 2019. The patient was diagnosed as not suffering from any form of cancer and was therefore referred on to the “benign” gynaecology team. Ms Nakafeero was advised that it was likely that the most effective treatment for her condition was a hysterectomy. It was expected that the likely wait for this treatment would be 6 months. Ms Nakafeero was not allocated an appointment and therefore had not received the necessary surgery by the time of her death in June 2022. Had the surgery been undertaken it is probable that she would not have developed a pulmonary embolism. Although the trust has investigated these circumstances and implemented change, no clear explanation could be offered for why the deceased slipped out of this care pathway. I am not satisfied that the risk of re-occurrence has been properly addressed. 2. The clinicians treating Ms Nakafeero assessed her VTE risk utilising an established algorithm based on national guidance. The assessment was undertaken appropriately but it failed to identify two risk factors which made the 2 formation of a DVT more likely, namely, large uterine fibroids and the use of tranexamic acid. I have concerns that the omission of these factors in the assessment criteria limited the effectiveness of the risk assessment.
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, 2023-0270
- 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
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