Angela Sandra Ivina West · Prevention of Future Deaths report

On 18 July 2017 I commenced an investigation into the death of Angela Sandra Ivina West (age 57). The investigation concluded at the end of the inquest on 12 June 2018. The conclusion of the inquest was a narrative conclusion which is set out in the section below. The medical cause of Ms West’s death was
1a: acute cardiac arrhythmia
1b: hyperkalaemia and hypovolemia
1c: end stage kidney disease
1d: lithium therapy for bipolar disorder
2: cholecystectomy

Angela West had end stage kidney disease, which required dialysis. She underwent surgery to remove her gall bladder at the Royal London Hospital on 6 July 2017. She initially recovered as expected. During 7 July, she became drowsy and had a slightly increased heart rate of 105 bpm. During 8 July, her heart rate increased over the course of the day. She also had increased inflammatory markers and reduced oxygen saturations. Her NEWS score increased from 2 to 5 over the course of the day. The possibility of a bile leak was raised and following a CT scan on the evening of 8 July, a decision was made to undertake a laparoscopy the following day. Once the possibility of a bile leak was identified, other potential reasons for her deterioration were not explored. It was decided that Ms West would have dialysis prior to undergoing laparoscopy because her potassium level was raised at 6.2. Ms West was not referred to the Critical Care Outreach Team until the morning of 9 July. In addition, she was not escalated to Consultants until the afternoon of 9 July. She remained tachycardic. She underwent dialysis during the afternoon. At the end of dialysis, her potassium levels were 4.1, lactates were 5.1 and her heartrate was 140 bpm, which was suggestive of hypovolemia. Ms West returned to her surgical wards around 6 pm. Whilst being assessed by the anaesthetist prior to surgery, she was found to have a respiratory rate of 40 breaths per minute and be tachycardic, confused and peripherally shut down. A venous blood gas showed that she had marked acidosis. Her potassium level was 6.1 and lactate was 10. Ms West went into cardiac arrest whilst being positioned for a chest x-ray. It was not possible to resuscitate her. Her death was confirmed shortly after 8 pm.

(1) Ms West was identified as being at increased risk of surgical complication given her underlying kidney disease. Ms West’s surgery was listed for a Thursday. The effect of this was that much of her care in the period following her deterioration was dealt with under weekend staffing arrangements.
(2) Ms West was located on a general surgical ward.
(3) The investigation highlighted issues relating to Ms West becoming dehydrated. Neither myself nor the clinical investigators were able to locate any fluid balance charts for Ms West.