Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0508, written 24 Nov 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 24 Nov 2014 |
|---|---|
| Reference | 2014-0508 |
| Deceased | Lara Mamula |
| Coroner | Caroline Sumeray |
| Coroner area | Isle of Wight |
| Category | Community health care and emergency services related deaths |
| Organisation named | Isle of Wight NHS Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
1.
2.
Ambulance Service
– A&E Consultant and Lead with the Isle of Wight
– Clinical Risk and Claims Manager, Isle of Wight NHS Trust
1
CORONER
I am Caroline Sarah Sumeray, Senior Coroner for the Coroner Area of the Isle of Wight.
2
CORONER’S LEGAL POWERS
I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009
and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.
3
INVESTIGATION and INQUEST
On 20th June 2013 I commenced an investigation into the death of Lara Mamula, aged
42. The investigation concluded at the end of the inquest on 13th November 2014. The
conclusion of the inquest was Natural Causes Contributed to by Neglect. The medical
cause of death was found to be:
1a Heart Tamponade
1b Ruptured Dissecting Aortic Root Aneurysm
1c Loeys-Dietz Syndrome
4
CIRCUMSTANCES OF THE DEATH
1) Lara Mamula was born on 1st July 1970. At the time of her death, she was 42
years of age.
2) On 11th May 2011 she presented with chest pain and tachycardia which was
treated as an emergency and she was found to have a Debakey type III aortic
dissection. She was kept under review until it was discovered that her aneurysm
had progressed and she then had planned surgery to repair her aneurysm on
22nd February 2012 which went well and she made a good post-operative
recovery.
1
3) Mrs Mamula was subsequently diagnosed with the rare Loeys-Dietz syndrome
at the Genetics Clinic on 24th July 2012.
4) Mrs Mamula remained under annual review by the Cardiology Team at
Southampton General Hospital.
5) On 12th June 2013, after having been pain free for 2 years, Mrs Mamula began
to suffer with chest pain, which she described as feeling very much like the pain
she had felt when she was initially diagnosed with her dissection 2 years earlier.
She called an ambulance crew out and they checked her over and could find
nothing wrong with her, but with her previous history they suggested that she
could be taken to hospital to be checked over. She declined their offer, but
agreed that she would see her GP the next day.
6) On 13th June 2013, Mrs Mamula attended her GP’s practice and saw
her GP. Mrs Mamula told her doctor about her chest pain and reiterated
that it was the same pain which she had felt some 2 years previously.
was very concerned and told Mrs Mamula to go straight to A&E. In order to
ensure that her patient saw the right doctor in A&E,
telephoned ahead
and spoke to 2 doctors, the first of whom was a physician who said that this was
not a matter for him; the second was
a Staff Associate Specialist
in Surgery who agreed to see Mrs Mamula and asked that he be contacted once
she was in A&E.
gave Mrs Mamula a copy of her Encounter printout to
show the doctors at the hospital.
7) Mrs Mamula attended A&E with her father. On arrival, she checked in at the
Reception Desk and was told to attend the Beacon Centre (GP practice within
the Hospital). Upon being triaged there, it became apparent that she needed to
be seen by a doctor in A&E, so she and her father were sent back to the A&E
department.
8) Mrs Mamula was seen by
an Associate Specialist in
Emergency Medicine at around 15.00 hours. She told him that she had a 2 day
history of epigastric pain radiating to her chest. He examined her and found that
there was no history of shortness of breath or heart failure. He noted that she
had had a thoracic aortic aneurysm repair 2 years earlier.
was not told
that she suffered from Loeys-Dietz syndrome, and indeed he had never heard of
such a condition before. He did not recall seeing her Encounter printout which
may have been handed in either to Reception or to the Beacon Centre.
9)
initially diagnosed gastritis with possible gastro-oesophageal reflux and
2
10) Crucially, the only piece of the patient’s presenting history which wasn’t passed
on to
was that Mrs Mamula claimed that the pain that she was feeling
was the same pain which she had felt back in 2011 when she suffered her
previous aortic dissection. Had
been aware of this piece of information,
his evidence was that he would have ordered a CT scan. Without that
information he did not have good cause to do so, in his opinion.
acknowledged that he had not sought out the CT imaging from Southampton
General Hospital as it was close to 5 p.m. and he believed that the clerical staff
would have left for the day. It is widely acknowledged that a chest x-ray is not
definitive when diagnosing an aortic aneurysm, but a CT scan is the “gold-
standard” way of diagnosing this condition.
11) Mrs Mamula was discharged from A&E by
after her symptoms
subsided and she had responded well to her treatment for gastritis. She was
discharged before seeing
He came down to A&E later only to find
that she’d been discharged, but even though he had had a conversation with
about her previous condition, he did not attempt to contact her to ask her
to return in order that he might examine her.
12) Mrs Mamula was told on discharge from A&E to keep taking her medications on
a regular basis, and if she was to become symptomatic again, she should
contact A&E again immediately.
13) Five days later, on 18th June 2013, Mrs Mamula’s husband returned from his
night shift at work and discovered his wife deceased on the floor of the lounge of
their house.
14) Life was pronounced extinct by a paramedic at 06.30 hours.
5
CORONER’S CONCERNS
During the course of the inquest the evidence revealed matters giving rise to concern. In
my opinion there is a risk that future deaths will occur unless action is taken. In the
circumstances it is my statutory duty to report to you.
3
The MATTERS OF CONCERN are as follows: –
1. During the course of the evidence, it became clear that the Isle of Wight
Ambulance Service did not appreciate the gravity of the situation when they
were called out by Mrs Mamula on 12th June 2013, inasmuch as they were not
aware that Loeys-Dietz syndrome predisposes those who suffer from it to have
repeated thoracic aortic aneurysms and dissections. Had they known that this
condition was so grave and that Mrs Mamula was complaining of the same pain
which she had suffered from 2 years previously which was clearly a very
ominous symptom, they could have impressed on Mrs Mamula that she would
have been much safer to have been taken to hospital at that point to be
thoroughly checked out with a CT scan, which would have been the only
definitive way to ascertain if she was suffering a new aortic dissection.
6
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you and/or
your organisation have the power to take such action.
7
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report,
namely by 19th January 2015. I, the Coroner, may extend the period.
Your response must contain details of action taken or proposed to be taken, setting out
the timetable for action. Otherwise you must explain why no action is proposed.
8
COPIES and PUBLICATION
I have sent a copy of my report to the Chief Coroner and to the following Interested
Persons: the family of Lara Mamula.
I am also under a duty to send the Chief Coroner a copy of your response.
The Chief Coroner may publish either or both in a complete or redacted or summary
form. He may send a copy of this report to any person who he believes may find it useful
or of interest. You may make representations to me, the Coroner, at the time of your
response, about the release or the publication of your response by the Chief Coroner.
9
H.M. Senior Coroner – Isle of Wight
24th November 2014
4
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