Dorota Kuklinska

Trust Headquarters 
Health and Wellbeing Centre 
Sandwell General Hospital 
Lyndon 
West Bromwich 
B71 4HJ 

Mrs Louise Hunt 
HM Senior Coroner  
Birmingham Coroner’s Court 
Steelhouse Lane 
Birmingham 
B4 6BJ 

15 March 2024 

Re: Dorota Marta Kuklinska (deceased) 

Dear Mrs Hunt,  

Thank you for your Prevention of Future Deaths letter of the 18 January 2024 raising the concerns 
you have regarding the NORSE referral pathway between Sandwell and West Birmingham NHS 
Trust and University Hospitals Birmingham NHS Foundation Trust.  

Sandwell and West Birmingham NHS Trust (SWB) have communicated with University Hospitals 
Birmingham NHS Foundation Trust (UHB) prior to the inquest and since the hearing to establish 
the process for NORSE referrals.  

As  explained  at  the  hearing,  the  SWB  guidance  follows  best  practice  as  informed  by  NICE 
Guidance  228  ‘Subarachnoid  haemorrhage  caused  by  a  ruptured  aneurysm:  diagnosis  and 
management’.  Unfortunately,  this  guidance  document  does  not  offer  a  pathway  for  those 
instances  where  a  patient  with  full  mental  capacity, makes  the  informed  decision  to  refuse  a 
lumbar  puncture.  In  line  with  the  Mental  Capacity  Act,  Mrs  Kuklinksa  was  given  appropriate 
information regarding the risks and benefits of the intervention and chose to decline a lumbar 
puncture. At this point, further investigations were not offered as they were not indicated in the 
NICE guidance.  

Working  with  UHB,  we  have  been  able  to  establish  their  internal  policies  state  that  a  ‘urgent 
neurology  opinion  should  be  sought  if  a  lumbar  puncture  is  unable  to  confirm  or  refute  the 
diagnosis  of  a  subarachnoid  haemorrhage’.  SWB  have  committed  to  aligning  our  internal 
guidance  with  UHB  by  updating  our  clinical  guidance  for  the  management  of  subarachnoid 
haemorrhage to include a requirement to seek a neurology opinion for those patients who either 
refuse or have an inconclusive lumbar puncture result. In circumstances where a patient with 
full mental capacity has refused a lumbar puncture, they would of course have to consent to the 
referral being made to UHB for the neurology opinion. This amendment is currently going through 
our internal governance processes and will be recirculated to staff when ratified.  

As  an  interim  measure,  the  sad  case  of  Mrs  Kuklinska  has  been  anonymised  and  used  as  a 
learning session with medical staff to ensure they are aware of the need for neurology referral. 

                                                                                            
 
 
 
 
 
 
 
 
 
 
 There is also a plan to share wider communications with medical teams through our regular Chief 
Medical Officer Bulletin.  

The  NORSE  referral  guidance  is an  internal  document  held  by UHB  clinicians  to  support  their 
management of referrals.  This guidance is not shared with referring clinicians which explains the 
misalignment of opinion on the day of the hearing.  Our decision to amend SWB’s guidance   to 
reflect that of UHB, will reduce future confusion. The policy amendments are anticipated to be 
signed off by 20 March 2024, with supportive communications following this.  

I trust this information will provide you with reassurance regarding the concerns raised in your 
report, however, if I can assist with anything further, please let me know. 

Yours sincerely 

Chief Executive

Executive Office of the Chair & Chief Executive 

14th March 2024  

Mrs Louise Hunt  
HM Senior Coroner for Birmingham and Solihull  

Dear Mrs Hunt 

Inquest touching the death of Dorota Kuklinska  
Response to Regulation 28 Report to prevent future deaths  

I write in response to the Regulation 28 Report made by you following the Inquest touching 
the  death  of  Ms  Kuklinska  which  concluded  on  29  January  2024.  You  will  recall  that  Ms 
Kuklinska was not a patient of this Trust but we will endeavour to assist with the issues raised 
within the Regulation 28 Report.   

University Hospitals Birmingham NHS Foundation Trust (the Trust) has carefully considered 
the concern raised within your report to prevent future deaths, which surrounds the guidance 
available to acute Trusts where there is strong clinical suspicion of an intracranial bleed due 
to cerebral aneurysm and when a referral should be made for specialist neurosurgical advice.  

, Consultant Neurosurgeon, that there 
During the Inquest you heard evidence from 
were guidelines in place which indicate that patients should be referred via the NoRSE referral 
system when there is a strong clinical suspicion of a brain bleed and particularly where they 
have refused a lumbar puncture.  To provide some context to 
 evidence, patients 
should be referred where there is a high index of suspicion of a bleed and specialist advice is 
required,  but  the  Trust  do  not  have  specific  guidelines  for  the  particular  scenario  where  a 
patient refuses  lumbar  puncture  or  any  other  assessment.  It  is  therefore  not the  case that 
there are guidelines that exist which have not been provided to SWBH/other acute Trusts.   

Guidance on the management of subarachnoid haemorrhage  
Subarachnoid haemorrhage (SAH) is not a rare diagnosis and the capability to diagnose SAH, 
or  to  have  a  clinical  awareness  of  the  potential  diagnosis  to  initiate  and  complete  relevant 
investigations are within the expected capabilities of a physician managing patients presenting 
to an emergency department.    

There is established national guidance (NICE guideline NG288) in place for clinicians when 
considering a possible diagnosis of SAH.  A diagnosis of SAH should be considered in any 
patient  with  a  severe  and  sudden  onset  or  rapidly  escalating  headache.  It  has  been 
established for many years that where SAH is suspected, there should be a CT scan of the 
head  and  if  this  is  negative/inconclusive,  a  lumbar  puncture  should  be  performed.   Both  of 
these tests are ordinarily performed at a referring hospital.   

 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
  
     
  
  
  
  
  
  
  
  
 Where a lumbar puncture is refused by the patient, it would not be practical or appropriate to 
refer  all  such  patients  to  a  specialist  tertiary  centre  without  further  action  at  the  referring 
hospital. Options available at the referring centre would include providing further advice to the 
patient  to ensure that the  risks  were fully  understood and consideration of  further  imaging, 
including CT angiography (CTA), which would detect an intracranial aneurysm and thereby 
assist in the diagnosis of SAH.  It would not be reasonable, as a function of the specialist team, 
to  re-assess  imaging  for  patients  solely  on  the  basis  of  their  refusal  to  permit  a  complete 
assessment whilst a patient is at the referring centre.  However, if the treating team have a 
high level of suspicion that there is SAH, then a referral to a specialist centre should be made 
for advice on further management.    

In Ms Kuklinska’s case, unfortunately, the clinical team were falsely reassured by the initial 
CT report and therefore did not consider CT angiogram and/or referral to the neurosurgical 
team.  Where there is a legitimate basis for neurosurgery referral (clinical suspicion of SAH), 
it is established practice for advice to be sought and scans to be shared with the specialist 
team for advice.   

Action taken  
The concerns raised have been considered and a detailed discussion has taken place at our 
neurosurgical governance day where the facts of this case were considered.  The consensus 
reached was that there is long standing guidance in place for the management and referral of 
patients with a diagnosis of SAH.  The scenario where the referring team had a high level of 
suspicion for SAH but there was a negative CT and LP was refused was also considered and 
in this scenario it was considered that the patient should be informed by the treating team of 
the clinical findings with a suggestion that a second opinion be obtained.  A CTA should also 
be considered.    

As referred to above, there are no specific Trust guidelines for the particular scenario where 
a patient refuses to follow medical advice/ best practice.  Where clinicians remain concerned, 
our on-call neurosurgical team can be contacted for advice.  

Whilst it is considered that there is well established guidance in place, having considered your 
concern, a letter will be circulated to all emergency departments in our catchment area to re-
iterate  the  established  pathway/  guidance  and  to  highlight  that,  if  there  are  concerns  with 
particular cases, our on-call team can be contacted for advice.   This letter will be circulated 
by 30 March 2024 and we would be happy to provide a copy to you.  

We have also discussed this case with the patient safety team at SWBH and have shared our 
internal guideline for managing SAH with them to assist in review of their own guidelines.  A 
, Hospital Medical Director QEH, and 
meeting has also been arranged between 
, Chief Medical Officer at SWBH to discuss any additional training/guidance that 

we can provide to support the clinical teams at SWBH.  

I would like to assure you that we have taken the concerns raised within the Regulation 28 
Report extremely seriously, which I hope is demonstrated in the steps we have taken, as set 
out above.   

Yours sincerely   

Chief Executive