Mrs Sarah Poole · Prevention of Future Deaths report

On the 4 April 2017, I commenced an investigation into the death of the late Mrs Sarah Poole. The investigation concluded at the end of the inquest on 16 May 2017. The conclusion of the inquest was a narrative conclusion: Natural causes contributed to by neglect.

The cause of death was:

1a Cardiac Dysrhythmia (Ventricular Fibrillation)
b Cerebral Anoxia/Brain Injury
c Acute Aortic Dissection with Aortic Rupture and Cardiac Tamponade (Operated 29/10/2016)
II Hypertension

i) Ms Poole was admitted to New Cross hospital after complaining of sudden onset of headache and back pain on the 28 October 2016 shortly after 11pm.

ii) An ECG performed by ambulance staff was abnormal. She was then triaged by nursing staff and assessed at Level 4 before being given pain relief medication.

iii) She was seen by a doctor at 1:50am who recorded a history of anxiety and panic attacks, headaches and pain in her back and chest. Her observations were normal and it was incorrectly concluded that her ECG was normal when the wrong ECG was examined relating to another patient.

iv) She was later discharged home and no discharge papers were given to the family.

v) Her condition continued to decline and she was readmitted back to hospital on the 29 October at around 1pm; a scan and further investigation revealed an aortic dissection.

vi) She then had emergency surgery which was a complex operation with associated risks.

vii) She developed further complications post operatively and by the 3 November a CT brain scan revealed minimal brain activity. She sadly passed away on the 5 November 2016.

1. Evidence emerged during the inquest that there were failures to record and endorse the name of the Doctor reviewing the ECG and a failure to take into account previous abnormal ECG results during the handover from the paramedic staff.