“Chloe explained on 11 March 2022 in Accident & Emergency to the doctor her background of…”

The coroner’s concerns

– a. Chloe explained on 11 March 2022 in Accident & Emergency to the doctor her background of complex trauma and how difficult she found it to be in hospital. This was not factored into a plan for treatment. a. Imaging established Chloe had swallowed 3 full-sized pens, 2 free in her stomach and 1 was impacted in her duodenum. There was a lack of consideration of the complexities of removal to guide whether the removal should be endoscopic or surgical. Endoscopy could not be converted into a procedure under anaesthetic in the interventional radiology suite. b. The requirement for reintubation after each pen removal and the difficulty for a patient to tolerate multiple procedures without anaesthetic was not considered for Chloe on referral for removal, or whether this might need to be converted to a procedure under anaesthetic. c. There was a lack of urgency in treating Chloe and lack of recognition of her deteriorating clinical condition. d. Chloe was tachycardic throughout her admission with low blood pressure and there was no investigation of the underlying cause in a young otherwise physically healthy woman. NEWS Scores should not replace consideration of the whole clinical picture for a patient. 2 e. In the hours before Chloe’s death, she required oxygen for the first-time that was administered for approximately 75 minutes and Chloe’s heart rate reduced to normal for several hours for the first time in her admission. This reduction was not sustained, and her heart rated elevated later. These changes were not recognised as signs Chloe was a deteriorating patient. f. Chloe’s low oxygen saturation level and the prescription of Oxygen was not documented on 14 March. g. From the timing of the recognition of Chloe’s in-hospital cardiac arrest there was approximately 10 minutes before the first heart rhythm was recorded during the resuscitation.

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, 2024-0329

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