Janet Hall · Prevention of Future Deaths report

On 10th October 2017, an inquest was opened into the death of Janet Hall, who died aged 67 years at Tameside General Hospital, Ashton under Lyne on 18th September 2017. The investigation concluded at the end of the inquest which I heard on 21st February and 12th March 2018.

The conclusion of the inquest was that Mrs Hall died as a consequence of acute heart failure. Although Mrs Hall had underlying ischaemic heart disease, her heart failure was precipitated by very advanced B Cell lymphoma which had not been diagnosed at the time of her death. The conclusion of the inquest was natural causes.

Mrs Hall first presented to her GP with symptoms of left leg and back pain on 22nd May 2017. The pain was not relieved by anti-inflammatories, and continued to progress with increasing analgesia requirements over the course of the summer.

On 19th July 2017, Mrs Hall attended the Emergency Department of The Royal Oldham hospital, complaining of palpitations and a raised heart rate. She was discharged following examination and investigations with a request that her GP arrange cardiology follow up.

On 9th August 2017, Mrs Hall attended her GP with leg swelling. Her GP referred her to the Vascular Studies centre at Tameside General Hospital where, the following day a scan confirmed the presence of an extensive Deep Veinous Thrombosis. Mrs Hall was admitted to hospital for further investigations, pain relief and anti-coagulant therapy.

There then followed a series of admissions and attendances to Tameside General Hospital, culminating in Mrs Hall’s sad death on 8th September 2017. The medical cause of Mrs Hall’s death was:

1)a) Acute left ventricular failure;

b) B Cell lymphoma on background of ischaemic heart disease.

Following Mrs Hall’s attendance at the Royal Oldham Emergency Department, a letter was written to her GP which included the text ‘Bloods and ECG all normal’. The evidence before the court was that contrary to this statement, Mrs Hall’s full blood count was, in fact, abnormal, with a slightly low haemoglobin at 96 grams / litre.

████████ Consultant in Emergency Medicine, explained in his evidence that in contrast to other systems which operate across the Trust whereby complete sets of results are automatically incorporated into discharge letters, the Emergency Department system is currently predicated on junior doctors accurately transcribing significant individual results.

In addition to increasing the chances for errors of the sort that occurred in this case, it is a matter of concern that the absence of a complete set of blood results in discharge letters reduces the potential for GPs to compare results with others on their own systems, reducing the opportunity for trend analysis.