Sonielia Laura Caya HOLMES · Prevention of Future Deaths report

On 10th May 2013 I commenced an Investigation into the death of Sonielia Laura Caya HOLMES, aged 23 years . The Investigation concluded at the end of the inquest on 21st October 2014. The Conclusion of the Inquest was a Narrative Conclusion: Sonielia Laura Caya HOLMES was admitted to Bedford Hospital on 17th April 2013 suffering from confusion and seizures; she had a history of tonsillitis for the previous two weeks. She was eventually diagnosed with Haemophagocytic Syndrome on 2nd May 2013 following a fall which, as a result of her blood disorder, caused a bleed in her brain. The brain injury resulted in a lost opportunity to treat her underlying condition and she deteriorated and died from Multi Organ Failure at 17:06 hours on 4th May 2013.

The Deceased was taken to Bedford Hospital South Wing on 17th April 2013 suffering acute confusion and seizures. She was very unwell and taken to the Critical Care Complex the following day. She had mixed clotting abnormalities and was ventilated and treated. She was returned to Ward on 22nd April 2013. She deteriorated again and got out of bed on 2nd May 2013 and fell over. A CT scan revealed extra cranial and intracranial injuries. She was taken back to the Critical Care Complex, ventilated again and had a repeated CT scan. A referral to Addenbrooke's Hospital and The National Centre for Neurology in London was made, but both stated that she was not suitable for further intervention. Her pupils had become fixed and she died whilst still receiving supportive treatment.

1. That on numerous occasions it proved impossible for the doctors attending Miss Holmes to contact the Haematology Department at the Hospital. This was despite the staff using all known contact details, including mobile phones and bleep numbers.

2. That the Haematologists working within the Hospital failed to respond to messages left for them to offer advice and to review Miss Holmes.

3. It was apparent from the evidence that Haematology is a vital service within the Hospital and any failure to respond to requests for assistance from other clinicians will put lives at risk.