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Investigation and inquest
On 4 July 2023 I commenced an investigation into the death of Sarah Chappell, aged 43 years. The investigation concluded at the end of the inquest earlier today. I made a determination as follows.
Sarah Chappell died from the recognised long term complications of necessary medical treatment. However, in addition to these, during her last admission to hospital her care was suboptimal because the appropriate team did not take charge. Placement of her nasogastric tube was not managed appropriately over her final weeks. If it had been, she would have survived this episode.
I recorded the medical cause of death as:
1a aspiration of gastric contents
1b adhesional small bowel obstruction
1c status post multiple complex surgeries flowing from an Arnold Chiari type II malformation with spina bifida & complicating hydrocephalus
2 metastatic adenocarcinoma of the rectum
Circumstances of the death
Sarah Chappell was transferred to University College London Hospital from the Princess Royal University Hospital in Orpington on 31 May 2023. She remained at UCLH until her death on 23 June 2023.
Coroner’s concerns
1. There was a ten day delay in Ms Chappell’s transfer from the Princess Royal Hospital to UCLH. I was told that this might have been because of a lack of beds, but it might also have been because of confusion about which UCLH site was the accepting surgeon’s preferred destination, a confusion that was understood at the time by the Princess Royal to be a rejection of the transfer.
2. From at least 16 June 2023, the consultant urology surgeon in charge of Ms Chappell’s care was very firmly of the view that he was not the best clinician to fulfil this role. He had long since correctly determined that she had not sustained a ruptured bladder, and thus considered that her care belonged with the gastroenterologists or the general surgeons.
Despite the agreement on 16 June of the gastroenterology clinical director that Ms Chappell’s care should be led by the gastroenterologists, they had not taken over her care by the time of her death, and there had not even been a conversation between the gastroenterology and general surgery consultants about the transfer of care.
3. There was a frequent misunderstanding among the medical staff that Ms Chappell’s issues were all chronic. Her acute situation was often not properly handed over or understood by her consultants.
4. Whilst at UCLH, the pain relief offered to Ms Chappell (principally simply paracetamol) was completely inadequate. At night, her buzzer was taken away from her and her door was shut.
5. The management of the nasogastric tube that was crucial in attempting to avoid a fatal aspiration was inappropriate. The tube in situ that was operating effectively was removed approximately ten days before her death. Her abdomen became extremely distended.
A further tube placement was not attempted until the day before she died. When this proved beyond the nurses’ skillset, a doctor was not called to assist until the following afternoon.
By then, two experienced doctors were unable to insert a tube and, as they were attending her (with her mother present), their patient suffered a massive aspiration and died shortly afterwards.
I was told at inquest that if the nasogastric tube had been passed at an earlier point, this would have been done successfully and the fatal cardiac arrest would have been avoided.
6. This death occurred almost six months ago, but no proper trust investigation has taken place, no changes in policies or procedures has been agreed, and the systems at UCLH remain largely what they were on the day that Sarah Chappell died.
Information checked against the published report and official responses