Open verdict on woman’s death in King's Lynn hospital
A coroner has voiced concerns about the frequency of checks undertaken on a hospital patient before she died.
An open verdict was recorded into the death of Kirsty Tolley, 28, at an inquest in Lynn on Tuesday.
Kirsty, of Walsoken, died at Lynn’s Queen Elizabeth Hospital on February 19 last year, having been admitted nine days earlier.
Senior coroner Jacqueline Lake said Kirsty had a number of health issues, including anaemia and epilepsy, and had a learning disability.
Mrs Lake said Kirsty had previously been admitted to the QEH in June 2016, when she was found to have acute anaemia and underwent surgery to relieve pressure in her leg. She also underwent a blood transfusion.
She was admitted to the hospital again in February 2017 with “bruising and pain in her legs”.
During her time in the hospital, she had regular blood tests to monitor haemoglobin levels, and was regularly observed and given early warning scores (EWS), which assess the degree of illness of a patient. On February 16, she was given Ferinject to treat iron deficiency.
The court heard that Kirsty died three days later in hospital, which came as a “complete shock” to medical staff, as they were expecting she could be discharged the following day.
A pathologist who initially stated the cause of death as an epileptic fit, with anaemia as a contributing factor said it should be changed to “unascertained” after hearing further evidence.
Mrs Lake said: “In light of the evidence I have heard, I record the medical cause of death as unascertained. There is no evidence to support any other possible outcome.”
She said there was an occasion on the evening of February 17 when an EWS was not taken, which meant there was a number of hours when observations were not completed. The court heard there was also a number of days when blood tests were not taken.
Regarding the EWS scores, hospital matron Karen Strong said: “I have no reasonable answer as to why those weren’t taken. I think the nursing staff do see the gravity of it.”
Dr Raj Shekhar, clinical director of medicine, said once patients are given Ferinject, blood tests are not take daily as the effects are not seen immediately.
Mrs Lake said she will produce a report to help prevent further deaths and suggested additional tests may have explained Kirsty’s death.
“Unfortunately the family are left in that position where they just don’t have the answers that could have been available,” she added.
