A coroner has raised urgent concerns over the “gross failure” in hospital care that “possibly contributed” to the death of a disabled woman, urging the NHS to implement improvements to prevent future tragedies.
Key Findings from the Inquest
Graeme Irvine, senior coroner for east London, conducted an inquest into the death of 27-year-old Chloe Every, from Dagenham, east London.
Every, who had learning disabilities and a muscle-wasting condition called myotonic dystrophy (MD), was admitted to Queen’s Hospital in Romford in April 2019.
During her hospitalisation:
Morphine was prescribed despite its known risks for individuals with MD.
She suffered a cardiac arrest on 8 May and later died on 14 May in pain and distress, according to her family.
Medical interventions, including the administration of an enema without consent, raised serious ethical and medical concerns.
Critical medical and nursing notes were missing, impairing the inquest’s ability to determine key decision-making processes.
Coroner’s Criticisms
The inquest revealed significant lapses, including inadequate monitoring, poor record-keeping, and a lack of specialist learning disability nurses. The absence of regular clinical observations was particularly alarming, with a 10-hour gap in monitoring reported.
The coroner’s Prevention of Future Deaths (PFD) report also criticised:
Staff’s inability to demonstrate appropriate criteria for initiating CPR.
Delays in reporting Chloe’s death to the coroner, compounded by the fact that her body had already been cremated by the time the inquest began, limiting evidence collection.
Response from the NHS Trust
Barking, Havering, and Redbridge University Hospitals NHS Trust acknowledged the failures and outlined actions to address them:
Mandatory staff training to enhance awareness of caring for patients with learning disabilities.
Improved record-keeping practices to ensure accountability and transparency.
Recruitment challenges in securing specialist nurses for learning disability care, particularly on weekends and holidays.
The trust admitted its initial investigation failed to adequately explore key issues, including the cause of Chloe’s cardiac arrest and the use of morphine.
Call for Systemic Change
The coroner emphasised that unless action is taken, there remains a risk of similar deaths occurring.
The PFD report has been sent to the chief coroner, the Care Quality Commission, and the local director of public health.
Ongoing Reforms
An oversight panel has been established to monitor patient safety incident handling.
The trust has pledged to improve its processes, but critics argue that the case highlights deep-rooted systemic issues within the NHS that require urgent attention.
