Nicola Valerie MARSDEN · Prevention of Future Deaths report

On the 22nd November 2012 I commenced an Investigation into the death of Nicola Valerie MARSDEN aged 35 years. The Investigation concluded at the end of the Inquest on 13th March 2014, where I brought in a Narrative Conclusion, the medical cause of death being:

I (a) Raised Intracranial Pressure
(b) Cerebral Haemorrhage

On the 14th November 2012 Nicola Valerie MARSDEN gave birth to her son at Bedford Hospital. Prior to, and immediately after the baby was delivered by Caesarean Section, she developed worrying neurological symptoms. An MRI Scan was carried out but was mis-interpreted and failed to recognise an haemorrhagic infarct. The serious nature of her condition was not recognised and this resulted in a lost opportunity to treat her appropriately and she died of a raised intracranial pressure due to a cerebral haemorrhage on 17th November 2012.

• That during the course of the evidence I was told that the brain scan relating to the deceased was mis-interpreted. The CT scans were viewed by a Radiologist and not a Neuro-Radiologist, despite the fact that there is a Guideline for having the scans viewed by a Neuro-Radiologist at Addenbrooke’s Hospital.

• My concern is that the interpretation of neurological scans and brain scans should be viewed and reported by Neuro-Radiologists and perhaps the Protocol for viewing of scans by non-specialists should be reviewed.