Chloe Every · Prevention of Future Deaths report

On 17th November 2023, this court commenced an investigation into the death of Chloe Every, aged 27. The investigation concluded at the end of the inquest on 21st October 2024. The court returned a narrative conclusion.

Chloe Every died in hospital on 14th May 2019. Chloe’s death was caused by complications of a cardiac arrest sustained on 8th May 2019 whilst in hospital.
The cardiac arrest on 8th May was probably contributed to by treatment given to Chloe to manage symptoms of bowel cancer.
It is possible that medical procedures undertaken to facilitate diagnosis of Chloe's cancer contributed to her death.
The inquest concluded that multiple actions and omissions of hospital staff during Chloe's inpatient admission did not comply with local and national guidance. Some of those omissions were actions that would have resulted in contemporary evidence being created relevant to this inquest.
I find that there is insufficient contemporary evidence to allow me to undertake proper assessment of all of the factors that are likely to have contributed to Chloe's death.

Ms Every’s medical cause of death was determined as;

1a Multi organ failure
1b Hypoxic Cardiac arrest, subsequent cardiogenic shock
1c Advanced Bowel Cancer (treated with Morphine)
II Myotonic Dystrophy

Chloe suffered from a genetic condition, Myotonic Dystrophy. She was also diagnosed with a learning disability.

In late 2018 Chloe was investigated for symptoms indicative of cancer. In late April 2029 she was admitted to hospital with upper right abdominal pain and an interrupted toilet habit. After diagnostic imaging, a preliminary diagnosis of colon cancer with metastases in the liver was arrived at.

Chloe was admitted into hospital awaiting a flexible sigmoidoscopy, planned for 8th May 2019.

Chloe's pain increased; she was prescribed morphine. No recorded justification for the use of this powerful drug can be found in hospital records. The identity of one of the prescribing doctors cannot be made out due to the absence of clear records.

On the morning of 8th May 2019, she underwent an enema. Before and during this process, Chloe was observed to be unresponsive. It is Moments after the procedure a crash call was raised as Chloe had sustained a hypoxic cardiac arrest, contributed to by the use of morphine. It is possible that the un-consented enema process contributed to the cardiac arrest.

Chloe was successfully resuscitated and was admitted to the ITU for supportive treatment.

After 5 days her care was stepped down to a respiratory ward, within a matter of hours of transfer, she was found unresponsive and declared deceased.

1. The Trust does not provide nursing cover during weekends and holiday periods of staff with relevant learning disability training.
2. The investigation of this inquest was prejudiced by the absence of contemporary nursing and medical notes from various stages of Chloe's treatment. The extent of these lapses meant staff who made important treatment decisions could not be identified, and where staff could be identified, no contemporary account of their rationale for making treatment decisions could be located.
3. The regularity of Chloe’s clinical observations fell well below the expected level. The lapses included a period of over 10 hours in which no observations were undertaken.
4. Chloe underwent an enema on 8th May 2019 without informed consent being taken. The court found that Chloe was unconscious, before, during, and after the procedure, it is possible this procedure contributed to her death.
5. Nursing staff were incapable of explaining to the court the appropriate criteria that would have to exist before commencing CPR on an unresponsive patient.
6. Governance processes at the Trust failed to identify that Chloe’s death constituted a patient safety incident until months after her death. A mortality review authored by the Associated Medical Director on 17th May 2019 assessed Chloe’s care as good or excellent.
7. A Serious Incident report completed by the trust in the second half of 2019 failed to identify a series of healthcare failings in Chloe’s treatment. Management failings at the Trust meant that Chloe’s death was not reported to a Coroner until August 2023, by which time Chloe’s body had been cremated denying the court an opportunity to gather relevant evidence through autopsy.