Ms Samia Yasmin Shara · Prevention of Future Deaths report

On 19th June 2013, I commenced an investigation into the death of Ms Samia Yasmin Shara aged 15years. The investigation concluded at the end of the inquest on 27th November 2014. The conclusion of the inquest was:

Medical Cause of Death

1 (a) Acute Heart Failure

(b) Aneurysm of Aortic Sinus and Ruptured Cusp of Aortic Valve.

How, when and where and in what circumstances the deceased came by her death:

Samia Shara suffered form an undiagnosed congenital heart problem. From around early April 2013 Samia began to experience intermittent shortness of breath and palpitations. She was seen in general practice and referred to cardiology. However before she was seen she suffered a rare acute complication of her heart problem which led to and caused her death.

Conclusion of the Coroner as to the death

Natural Causes

It was clear from the evidence taken during the inquest that she suffered an acute rupture of one of the cusps of her aortic valve causing her to go into crashing heart failure. Her brother attempting to seek urgent medical advice on her behalf and made calls to 999 and 111. For various reasons she was not recognised by the call takers to be as unwell as she was until the final call to 999 such that the provision of emergency LAS services were delayed. This delay was not causative in her death on the balance of probabilities, but various incidents occurred, such as the downgrading of the call by a call taker and a failure to re-triage when the brother called back by a call taker.

(1) That long and complex calls made to 999 and 111 should be available for audit by the CCG to identify learning opportunities and thus improve outcomes via a quality assurance process.
(2) That call takers should not be able to downgrade a call by moving to a pathway of lower acuity.