Johanna Moreland

Medway Maritime Hospital 
Windmill Road 
Gillingham 
Kent 
ME7 5NY 

OFFICE OF THE CHIEF MEDICAL OFFICER 

3rd September 2021 

Ms Sonia Hayes 
Assistant Coroner 
Mid Kent and Medway Coroners 
Cantium House 
County Hall 
Sandling Road 
Maidstone 
Kent 
ME14 1XD 

Dear Ms Hayes, 

Prevention of Future Deaths Regulation 28 Report – Johanna Moreland 

We refer to your report issued following the inquest touching upon the death of 
Johanna Moreland dated 11th July 2021 pursuant to Regulation 28 of the Coroner’s 
(Investigations) Regulations 2013. 

Background: 

Mrs Moreland was admitted to Medway Maritime Hospital on 13th February 2021 with 
an infective exacerbation of her COPD and there were concerns about her 
behaviour.  She underwent investigations and her liver function tests were deranged.  
Unfortunately she self-discharged against medical advice on 16th February and 
sought a private liver scan, but before that took place Mrs Moreland re-attended 
Medway Hospital on 19th February 2021. Psychiatric review revealed no mental 
disorder to explain her unusual behaviour, and a lumbar puncture was performed on 
26th February 2021 to investigate possible encephalopathy as a cause. The initial 
results were normal but the enhanced results revealed Herpes Simplex virus which 
was treated with anti-viral medication. 

Mrs Moreland had advanced liver metastases and imaging indicated a possible 
primary lung cancer, therefore a biopsy was performed on 4th March 2021 intended 
to confirm the diagnosis, to stage the cancer and then make a palliative care plan.  
The biopsy carried a risk of bleeding due to Mrs Moreland’s advanced liver disease 
and she did suffer a bleed post procedurally. Mrs Moreland was not suitable for 
surgical intervention due to her advanced liver cancer and sadly continued to 
deteriorate, passing away from the intra-abdominal bleed on 8th March 2021. The 
biopsy hastened her death by a short time. 

 
 
 
 
 
 
 
 
 
 
 
 
  
 
 The following is our response in relation to the matters of concerns raised:  

(1) Results from lumbar puncture taken on 26th February 2021 were made 
available on 4th March 2021. Evidence heard at the inquest was that 
Lumbar Puncture tests are usually for diagnosis of serious illness and 
would usually be made available within 24-48 hours. 

The Trust has investigated the timeframe for the availability of Mrs Moreland’s 
results. The cerebrospinal fluid (CSF) sample was taken on Friday 26th 
February 2021 and was received at the Pathology department at 17:28 on the 
same evening. The standard cell count, protein and glucose levels and 
bacterial screening and culture, performed in our microbiology laboratory at 
North Kent Pathology Services based at Dartford, was available within normal 
turnaround time of 24-48hrs and was unremarkable. 

The molecular investigation for viral pathogens (including the Herpes Simplex 
virus) is an outsourced function, carried out by external laboratory 
Micropathology in Coventry on behalf of the Trust. The published turnaround 
time is 10-14 working days for viral pathogens including Herpes Simplex virus. 
The sample was sent to the external lab on Monday 1st March 2021. The 
regular transport to external laboratories is Monday to Friday, leaving just 
before 17:00. Specimens are not sent to external laboratories on Saturdays 
and Sundays because most laboratories will not process these over the 
weekend and a specimen will wait too long in conditions that may lead to 
deterioration.  

In Mrs Moreland’s case, the specimen was received at the external laboratory 
on 3rd March 2021 with the result available late that evening and sent by 
email. The result was uploaded to the Trust’s system the next day on 4th 
March 2021 in line with our procedure, and was communicated to the ward at 
this time. These results were thus received within the normal turnaround time 
for this particular investigation. 

(2) The Lumbar Puncture results were positive for encephalitis and in the 
absence of the tests results, a liver biopsy was conducted and, there 
was a delay in antiviral treatment commencing.   

The lumbar puncture procedure was carried out to investigate encephalopathy 
as a possible cause for Mrs Moreland’s ongoing confusion and erratic 
behaviour as there had been no mental health cause found on assessment, 
and antibiotic treatment was not resulting in improvement.  

The biopsy procedure Mrs Moreland underwent was performed as Mrs 
Moreland had evidence of metastatic cancer in the liver without an identified 
primary tumour. Imaging undertaken appeared to show a possible primary 
tumour within her lung, however it is now known after post mortem that the 
tumour in Mrs Moreland’s liver was the primary tumour. 

 
 
 
 
  
  
  
 
 
 
 These investigative processes were carried out independently of each other to 
explore separate medical concerns; the biopsy was not carried out as a result 
of any delay in receipt of the lumbar puncture results.  

Mrs Moreland was administered Clarithromycin and Co-Amoxiclav for 
treatment of infective exacerbation of COPD from her admission on 13th 
February 2021 until she took her on discharge on 16th February 2021. Upon 
readmission on 19th February 2021 Mrs Moreland was recommenced and 
maintained on IV antibiotics whilst awaiting results from lumbar puncture. The 
preliminary culture results returned were normal and not indicative of a 
change in treatment. However, the results of the viral pathogen test available 
on 4th March indicated Herpes Simplex virus and upon Microbiology advice 
treatment was changed to anti-viral Acyclovir. Please see (1) regarding 
turnaround times for complex DNA results. 

(3) The Trust policy on the required levels of observations following a liver 

biopsy were not followed on return to the ward due to a 
miscommunication between Trust staff and the required levels of 
observations was not recorded in the medical records. 

Trust policy is for observations to be carried out every fifteen minutes for the 
first two hours post procedure. Mrs Moreland’s observations were completed 
pre-procedure at 11:10, the procedure was completed in Interventional 
Radiology at 12:48, and Mrs Moreland’s next documented set of observations 
were at 15:38 with a NEWS of 1. Patients would usually be recovered in the 
Interventional Radiology department, however our investigation has indicated 
that Mrs Moreland was returned to the ward earlier than a patient would 
normally be due to Covid precautions.  

This report from the Coroner has identified an opportunity for improvement to 
process within the Trust, and to reduce the likelihood of any similar 
circumstance the Trust has developed the attached handover form to be 
competed post every procedure (Appendix 1). This process is led by the 
Consultant Radiologist and will include written confirmation of frequency of 
observations to be carried out, as well as written confirmation of handover to 
nursing staff. Trust policy for post procedure observations has been reiterated 
to all nursing staff subsequently through consistent inclusion in the Trust’s ‘Big 
4’ ward based messaging. 

We thank the Assistant Coroner for raising this with us and highlighting the 
opportunity for an improvement in our process. 

 
 
 
 
 
 
 
 
 
 
 Yours sincerely,  

Chief Medical Officer 

Appendix 1 – Ultrasound Guided Biopsy Procedure Chart