Elizabeth Agbejimi

United Lincolnshire Hospitals  h'J:kj 

NHS Trust 

Legal Services Department 
Trust Headquarters 
Lincoln County Hospital 
Greetwell Road 
Lincoln 
LN2 5QY 

HMC Mr Paul Cooper 
Assistant Coroner for Lincolnshire 
Gilbert Drive 
Endeavour Park 
Boston 
Lincolnshire 
PE21  7TQ 

Date:  31  August 2023 

Dear Mr Cooper, 

Inquest Touching the death of Elizabeth Oluwatofunmi AGBEJIMI 

Thank you for providing us with a copy of the Regulation 28 Report to Prevent Future Deaths 
('the Report'). This document is the response from the United Lincolnshire Hospitals NHS Trust 
('the Trust'). 

At the outset, the Trust would like to express our heartfelt condolences to Elizabeth's family and 
friends for their loss. 

Response to issues raised  by the Report 

The Trust was not granted interested person status at the inquest,  and as such did not have the 
opportunity during the inquest itself to provide the additional information to the Court and the 
family to provide the reassurances understandably now sought.  It is however hoped that this 
information below Will  reassure the Coroner that the findings have been given serious 
consideration by the Trust and appropriate reflection and learning ~ndertaken. 

In writing this response, without direct access to the full content of your report, we have made the 
following positive assumptions: 

•  Your concern is that the abnormalities found on the venous blood gas sample 
taken on  12 June 2021  showed evidence of respiratory compromise that may 
have been a sign  of the pneumonia which was diagnosed on Elizabeth's second 
admission and that the abnormalities found on the venous blood gas sample was 
not related to possible chronic but relatively stable problems. 

•  That the pneumonia was the consequence of immobility arising from injuries 
sustained from the'falls which are attributed as the direct cause of death. 

We note that the matters of concern in  Paragraph 4 of the report relate to evidence given by the 
intensive c;are  consultant 
gas sample undertaken on  12th June 2021  were not investigated further. You  have asked us 
whether there was or still is a training or communication issue. 

 that the abnormalities demonstrated on the venous blood 

 
 
 We have taken the time to review the case notes carefully to address your concerns and identify 
potential learning points. 

On  12 June 2021, the initial blood gas was taken at 13:17. A signature was placed on the results 
report. The signing of blood gasses by ED clinicians is standard practice as this denotes that a 
clinician has seen the gas results and acknowledges any abnormalities so that any further action 
required can  be taken. There is no evidence of identification .of the potential acute type 2  · 
respiratory failure with chronic metabolic compensation documented in the clinical records.  For 
context, an acute Type 2 respiratory failure is where arterial oxygen levels are low and  carbon 
dioxide levels are high along with a low blood pH.  The metabolic compensation refers to the 
bicarbonate levels which elevate to correct the reduction in pH  caused by the high carbon dioxide 
levels. In this case, the venous blood gas test cannot however categorically diagnose an acute 
Type 2 respiratory failure as the oxygen levels are always lower on  a venous sample, and arterial 
oxygen levels are always higher. 

High carbon dioxide levels in  a patient's blood can manifest as symptoms of drowsiness and 
confusion, which were documented symptoms in  Elizabeth's case. We acknowledge that there 
was no documentation either on the gas result or in the notes requesting that the sample taken 
on  12 June 2021  be repeated after treatment to ensure this is not a spurious result or to 
demonstrate that treatment had been successful in correcting the abnormality. 

We acknowledge that there is no documented plan to investigate the result further.  Such 
investigations would include a chest x-ray which may have been helpful to identify an infection 
earlier. This may well be compounded if the clinician checking the gas is not the clinician seeing 
for the patient and therefore, they do not have the benefit of a full clinical picture of the patient's 
symptoms as they have not been adequately documented 

A decision to admit Elizabeth under the medical team was made at 14:45. Review of the notes 
from the Emergency Department ('ED') doctor who saw Elizabeth do not refer to the blood gas 
result at any point but did make a provisional diagnosis of  an infection as a cause of her 
symptoms. The ED doctor recorded Elizabeth's low blood pressure and noted that this may 
constitute infection despite the normal blood values. They also made note of Elizabeth's lethargy 
which is then subsequently commented on by the medical team. Antibiotic therapy was 
commenced which would typically cover both the suspected urinary symptoms and a respiratory 
infection which was suspected as the cause of her symptoms. 

It was noted that Elizabeth was to be seen by the medical team at 16:30 and again at 20:00. 
They note an increasing level of consciousness returning closer to baseline, but a venous gas 
taken at about 17:00 d.emonstrates a worsening of the original values. The notes indicated that 
the medical team identified issues which would require input from the orthopaedic team. There is 
then discussion in the notes which ends with the medical team concluding that there was no 
further medical input required to treat the potential infection identified by the emergency team 
and Elizabeth was transferred to the orthopaedic ward.  Elizabeth was discharged from the 
orthopaedic ward at 00:45 following a stay of 12 and a half hours. 

Learnings and Actions 

Upon reviewing the case we can  see that there are two main areas of learning which we are 
committed to improving. 

1.  Ensure better documentation of the identification of the abnormalities on the blood gas 

results 

All  ED clinicians who are acknowledging blood gas results are now required to document: 

• 
• 

any abnormality that needs further management and 
the planned further management for example by prescribing medications, 
documenting an x-ray request or documenting a request for a repeat gas. 

 2.  Ensure clinicians recognise the  potential altered response to infection seen amongst 

those affected by Trisomy 21. 

We see this as an educational opportunity to ensure that clinicians recognise the 
potential altered response to infection seen amongst those affected by Trisomy 21. A 
significant infection can manifest very differently in this group and a lower threshold for 
investigation and admission for these patients is prudent. 

This will be communicated onto the ED Team and other teams involved in this case along 
with a reminder to admitting teams to fully review the ED  notes. 

In  order to assure that these processes have been embedded, the clinical audit team in  both 
ULHT departments will undertake an  audit of blood gas results and the documentation in them to 
review the learning and actions have been embedded. 

We understand that documentation and  communication between clinicians is incredibly important 
for patient safety and we are committed to continue to use adverse events as learning 
opportunities to ensure ongoing patient safety and continual improvement. 

We hope that this response is satisfactory and addresses the concerns you have outlined. 

Yours Sincerely, 

  Subject: Fw: Draft PFD response- 25_8_23.DOCX 

Pleas see attached- for governance input 

Need to audit blood gas results in 6 months 

look at all VBG taken 

• 
•  Highlight abnormal 
•  Look at documentation of abnormal 
•  Present results please 

Associate Clinical Director for Medicine\Consultant EM 

United Lincolnshire Hospitals NHS Trust 

Emergency Department 

Lincoln County Hospital, Greetwell Road, LN2 5QY 

OUTSTANDING CARE personal!g DELIVERED