“2 Neurology departments are so overwhelmed and/or understaffed that a vulnerable young…”

The coroner’s concerns

2 Neurology departments are so overwhelmed and/or understaffed that a vulnerable young girl (particularly so during the Covid-19 pandemic), was not referred in a timely manner to adult neurology services and in fact, it transpired a referral had not been made at all. This appears to have been done for the first time in August 2021. An initial consultation with a complex non-verbal patient was arranged over the telephone, notwithstanding the concerns about a tremor which would have required visual assessment. An overworked consultant under considerable pressure, did not have time before or during the consultation to establish the dose that Chloe was taking and/or apply the appropriate conversion factor, for medications that can interact negatively at higher doses. No note was made of the tapering regime for the medication change in Chloe’s notes. A handwritten note of a tapering regime based on incorrect doses was sent to Chloe. The same regime was repeated in a letter to the Epilepsy Nurses, but this letter was not received until October 2021 (in paper form) as the initial email was sent to an address that no longer existed. Phone calls and messages left with the neurology department went unanswered, at a time when clarity over the tapering regime was needed. The consultant in question gave evidence of a very bleak picture of ongoing practice in the neurology department; a letter from all four consultants in that department had been sent to the Trust in July 2023, where patient care was described as ‘sub-optimal’, and numerous concerns were set out including: o Chronic staff shortages in respect of doctors, nurses and administrative staff within the neurology department o Substantial and unsafe backlogs for first and follow up appointments o Inability to answer, in a timely manner, the volume of phone calls, phone messages and emails from patients/carers raising queries. o The delays / ways in which investigations are carried out and reported, and the way in which clinical staff can access results. A further letter was sent by Chloe’s consultant in January 2024 in lieu of her attending a meeting where progress was to be discussed. That letter highlighted that, not only did the concerns remain live, she believed that the department had now reached levels of ‘unsafe practice’. The state of the department, compared to when Chloe died was described as ‘worse’. Notwithstanding Chloe’s death in 2021, the letter in July 2023 and follow-up in January 2024, many of the more significant actions identified remained as part of an Action Plan. Business cases were being drawn up for a number of areas (but not additional consultants) and these had not yet been approved, nor was it guaranteed that they would be. The independent consultant neurologist in giving evidence expressed that this 3 was not an unfamiliar picture across a number of different Trusts and that there was a recognised shortage of neurologists and increase in demand for that speciality nationally.

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, 2024-0111

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