Patricia CURTIS · Prevention of Future Deaths report

On 21 April 2021 I commenced an investigation into the death of Patricia CURTIS aged 80. The investigation concluded at the end of the inquest on 21 November 2024. The conclusion of the inquest was that:
Patricia Curtis died as a result of a known, but extremely rare complication of necessary post operative treatment

Mrs Curtis underwent mitral valve repair, tricuspid valve repair, coronary artery by pass grafting x 3 and atrial appendage exclusion on 17 March 2021 at Royal Papworth Hospital. Her post operative recovery was lengthy and she was repatriated to Bedford Hospital on 1 April 2021. On 2 April 2023 following arrival at Bedford Hospital Mrs Curtis deteriorated rapidly in the early hours of the morning. Post mortem examination determined that her cause of death was a haemothorax which on the balance of probability had started to develop gradually following a removal of her chest drain at Royal Papworth Hospital before transfer to Bedford Hospital. Clinical signs of the haemothorax were first identifiable at 1am on 2 April 2021 when Mrs Curtis' medical assessment detected decreased air entry on her left side following prior examination results which showed equal air entry. Haemothorax did not form part of the differential diagnosis for Mrs Curtis at 1am on 2 April 2021 and she continued to be treated for her presenting complaints of fast atrial fibrillation, low blood pressure and severe heart failure and possible myocardial ischaemia due to low blood pressure. A chest X-ray was not considered to be necessary as Mrs Curtis was not presenting with a primary lung cause and her respiratory system did not seem particularly affected at that time. It is not possible to say whether a chest X-ray would have identified a haemothorax. It was recognised by the treating clinicians that Mrs Curtis was very unwell and it was determined that Mrs Curtis would be unlikely to survive Intensive Care Unit care.

Hospital Discharge notes are not uniform across Hospital Trusts. This carries the risk of essential patient information not being available to treating clinicians when a patient is received into a new clinical setting, leading to potential delay in providing life saving care and treatment.