The inquest into the death of E* was heard over four days, concluding in January 2024. The inquest was before HM Senior Coroner Emma Whitting at Bedfordshire and Luton Coroner’s Court.

E died on 9th January 2022 from cardiac failure, whilst detained under section 3 at an acute female mental health unit. E was highly vulnerable and suffered from complex, inter-related mental and physical health needs.

E was subject to 15 minute observations at the time of her death. In the lead up to her death, the observations were not consistently carried out at the required intervals and the standard of checks were variable. Three different staff members omitted at least one of their prescribed observations and recorded false entries to suggest these had been done.

There was also a delay in the emergency response, including an 8-minute lapse between E being found and 999 being called.

It came out during the inquest that an ultrasound abdominal scan had been requested whilst E was detained on a previous ward and the scan was not followed up appropriately. The scan was undertaken on 30th June 2021 and identified multiple large kidney stones in E’s left kidney.

Following discharge from the ward, the onus of following up the scan was on the GP; however, due to an administrative error, the report was not actioned and E was not referred to the Urology Team for further management. Had E been properly referred, in normal times (i.e. unaffected by the Covid-19 pandemic), E would have had surgical intervention to either remove the stones or to remove her left kidney, by December 2021.

A Consultant Urologist gave evidence that the continuing presence of the left kidney stones would have contributed to her death but was not aware of any previous cases where kidney stone disease had directly caused death.

Following submissions made by the family’s representative, the Coroner gave a narrative conclusion, including that her heart failure was exacerbated by the continuing presence of kidney stones which had been diagnosed 6 months prior to her death but not removed.

The Coroner has written to the GP surgery who now have to respond, informing the Coroner of the action taken to ensure that this administrative oversight (the failure to follow up on the scan results) does not reoccur.

E’s family were represented by Alice Wood of Farleys Solicitors and Laura Profumo of Doughty Street Chambers.

To speak to a specialist in our inquest team, please call 0845 287 0939, get in touch by email, or use the online chat below.

*This case study has been anonymised at the request of our clients.