Mary Patricia MULDOWNEY · Prevention of Future Deaths report

On 26 July 2016, I commenced an investigation into the death of Mary Muldowney, aged 57 years. The investigation concluded at the end of the inquest earlier today. I made a narrative determination, which I attach.

Ms Muldowney’s medical cause of death was:

1a spontaneous subarachnoid haemorrhage (operated 20.07.16)
1b right posterior communicating artery rupture.

She was admitted to East Surrey Hospital at about 10am on Wednesday, 20 July 2016 and an intracranial bleed was immediately suspected. A CT scan performed at 11.11am demonstrated subarachnoid and subdural bleeds. Transfer to a specialist neurosurgical unit was sought as a matter of urgency.

However, the transfer was refused by St George’s Hospital, Royal Sussex Hospital, King’s College Hospital and others, on the basis that they did not have an available intensive care bed.

In desperation, knowing of the neurosurgical expertise of a former colleague, one of the East Surrey Hospital doctors went out of area and rang a consultant neurosurgeon at the Royal London Hospital (RLH). Invoking the universal acceptance policy [see Wells 1996], he accepted transfer immediately, though in fact the RLH had no intensive care bed available at that time.

Meanwhile, at about 1pm, Ms Muldowney woke up very briefly while intubated and interacted with her daughter.

Ms Muldowney was at high risk of a re-bleed. The 2013 National Confidential Enquiry into Patient Outcome and Death (NCEPOD) subarachnoid haemorrhage audit only recommended that sub arachnoid haemorrhages be treated within 48 hours. However, I heard evidence that this lady was obtunded, she was under anaesthetic, and her ruptured aneurysm was complicated by a sub dural haemorrhage, so she needed surgery immediately, regardless of whether there was an intensive care bed currently available at the same hospital.

Ms Muldowney was transferred to the RLH and taken straight to theatre at 4.40pm. Unfortunately, her pupils had become fixed and dilated in the ambulance during transfer to the RLH and surgery did not save her. If she had been transferred promptly, it probably would have.

In the light of the gravity of Ms Muldowney’s situation, with the only definitive treatment being surgery, she required immediate transfer to a specialist neurosurgical unit, yet she was refused transfer by at least three hospitals who said they had no intensive care beds.

She could have been transferred, undergone surgery, spent time in recovery, and then an intensive care bed procured, perhaps even by transferring out a non neurosurgical patient.

If such a bed was still unavailable, she could then have been transferred to a different hospital, at least having undergone the time critical clot evacuation and aneurysm clipping.

With prompt transfer and surgery, Ms Muldowney would probably have survived.