Nuala Seddon · Prevention of Future Deaths report

Nuala Seddon died on 7 April 2016, from the consequences of hypoxic brain injury which resulted from an episode of cardiac arrest on 27 November 2014. The inquest into Mrs Seddon’s death was conducted on 3 February 2017. I recorded a narrative conclusion, which is attached.

Mrs Seddon was admitted to Whittington Hospital in November 2014 with a recurrence of a left-sided pneumothorax. She was transferred to UCLH’s Heart Hospital (a hospital which has now been transferred to Bart’s NHS Trust). The intention was for her to undergo a procedure to treat the air leak which had caused the pneumothorax and also address the risk of future recurrence. Unfortunately the procedure was unsuccessful and resulted in tracking of air under the skin (‘surgical emphysema’) and a further pneumothorax on the right-hand side.

Mrs Seddon was admitted to ITU at the Heart Hospital and improved to a certain extent. On 27 November 2014 the initial decision, after the morning ward round, was for her to remain under the care of ITU. However, between 4-5pm that day it is clear that she was discharged to ward-based care. The rationale for this discharge is unclear as no documentation was available to explain the change in plan. The potential was raised by the ITU consultant that discharge resulted from a non-clinical manager’s decision because of pressure on bed spaces. There was no evidence this was the case and ultimately the clinicians who gave evidence at the inquest were satisfied that the decision to discharge Mrs Seddon to the ward was reasonable.

After arriving on the ward Mrs Seddon had observations performed which warranted a review by ITU outreach nurses (as was planned in any event). They were satisfied that the trend of these observations was in keeping with Mrs Seddon’s known history. However, the nursing plan was for increased monitoring, to include attempting to institute telemetry and moving Mrs Seddon to a bed which was more visible from the nursing station. No telemetry was available and, before the plans for moving beds could be undertaken, Mrs Seddon was found to be unresponsive and in cardiac arrest.

She was successfully resuscitated but the period of cardiac arrest resulted in hypoxic brain injury. I heard evidence that the level of monitoring undertaken on the ward more than minimally contributed to the development of the brain injury.

Despite transfer to ITU, initially at the Heart Hospital and subsequently at the Whittington Hospital Mrs Seddon’s condition did not substantially improve. Plans were put in place for transfer for neurorehabilitation but she developed a terminal episode of pneumonia which, despite treatment with intravenous antibiotics, resulted in her death on 7 April 2016.

(1) I heard evidence from the ward nurse that concerns regarding lack of available telemetry remain a current issue at the Heart Hospital (which is now part of Barts NHS Trust). This raises a concern that patients who are discharged from the highest level of clinical care on ITU are then exposed to significant risk of unrecognised deterioration, owing to a lack of appropriate monitoring.