Kirsty Michelle Hendry · Prevention of Future Deaths report

On 18th April 2023 I commenced an investigation into the death of Kirsty Michelle Hendry. The investigation concluded on the 8th September 2023 and the conclusion was one of Narrative: Died from the complications of a subarachnoid haemorrhage caused by a burst aneurysm which was not diagnosed until vasospasms had severely compromised her neurological status and she could not be successfully treated. The medical cause of death was 1a) Cerebral Infarction; 1b) Vasospasm; 1c) Spontaneous Subarachnoid Haemorrhage

On 30th March 2023 Kirsty Michelle Hendry was seen at her surgery by an advanced nurse practitioner. She presented with a headache and vomiting which had started two days previously. She was prescribed antibiotics for a suspected infection. It is probable that the symptoms were due to a subarachnoid haemorrhage due to a burst aneurysm. A hospital referral at this point would probably have identified the subarachnoid haemorrhage and allowed preventative treatment to reduce the risk of her developing severe vasospasm. On 2nd April 2023 an ambulance was called as she was feeling unwell. The ambulance crew did not recognise that her behaviour was inconsistent with her usual presentation. She was taken to Tameside General Hospital where there was a prolonged wait to be seen. A CT scan undertaken showed evidence of a subarachnoid haemorrhage that had occurred previously around 28th March 2023. The scan was incorrectly reported as being clear. At Tameside General Hospital her consciousness levels were reduced, and she was agitated. She had probably developed a severe vasospasm from the subarachnoid haemorrhage. Treatment options at this point are extremely limited. An MRI scan on 5th April 2023 showed multi territorial infarctions and significant narrowing of all the intracranial vessels. On the balance of probabilities, the neurological situation was probably irreversible on her admission to Tameside General Hospital. She was transferred to Salford Royal Hospital where attempts to treat her were unsuccessful. She died at Salford Royal Hospital on 11th April 2023.

The inquest heard evidence that early identification of a burst aneurysm is vital if treatment is to be offered at an early enough stage to reduce the risk of death. The inquest was told that particularly in primary care the symptoms are not readily understood and awareness is often low. In Kirsty Hendry’s case she had the key symptoms that are linked to a burst aneurysm.
The evidence was that it was important awareness be raised so that all doctors and other health professionals carrying out examinations in a primary care setting should understand the key symptoms /presentation of a burst aneurysm so that appropriate referrals could be made to secondary care and CT scans be undertaken at an early stage when the probable could be easily identified and treatment options were available.