Sheila Creagan · Prevention of Future Deaths report

On 26th March 2025, this court commenced an investigation into the death of Sheila Creagan aged 81 years. The investigation concluded at the end of the inquest on 10th March 2026. #

The inquest concluded with a Narrative conclusion,

“Sheila Creagan died on 17th March 2025 due to infective endocarditis, a condition that was neither treated, nor diagnosed during her final, 14 day admission to hospital. Mrs Creagan's endocarditis was caused by bacteria entering her bloodstream as a consequence of abdominal surgery undertaken in February 2025. The bacteria lodged and multiplied upon calcified nodules on Mrs Creagan's mitral valve, a symptom of chronic cardiac illness. The bacterial vegetation on the valve caused haemorrhage which, in turn, caused a cardiac arrest.”

Sheila Creagan’s medical cause of death was determined as;

1a Bacterial Endocarditis
1b Subacute Intestinal Obstruction (operated on)
1c Peritoneal Adhesions (previous appendicectomy and cholecystectomy)
II Ischaemic and Hypertensive Heart Disease

Mrs Creagan was an 81-year-old woman with extensive comorbidity including heart failure. Sheila underwent emergency abdominal surgery on 5th February 2025 for adhesiolysis. The surgery was uneventful, but Mrs Creagan’s post-surgical recovery was complicated leading to delayed discharge from hospital on 27th February 2025.

On 3rd March 2025 Mrs Creagan was admitted to hospital by ambulance with difficulty in breathing, anaemia and a suspected GI bleed. Mrs Creagan was treated for pneumonia and fluid overload. A blood transfusion was administered. Imaging investigations found no haemorrhage or significant abdominal complication of surgery.

By 14th March 2025 the trust determined that the chest infection had resolved, despite that Mrs Creagan’s infection markers continued to climb, and her National Early Warning Score (NEWS) deteriorated.

Neither a septic screen nor an echocardiogram was undertaken (having previously been requested).

Mrs Creagan died in hospital on 17th March 2025 which both the attending physician and medical examiner offering a cause of death incorporating pneumonia as the primary, direct cause of death.

An autopsy found no sign of extant pneumonia at the time of death and identified bacterial vegetations on the chronically calcified leaflets of the mitral valve in the heart as the primary cause of death.

1. BHRUT chose not to investigate this case as part of NHS England’s Patient Safety Framework. Mrs Creagan’s death ought to have been subject to such an investigation.

Decisions were reached at two clinical governance meetings that meaningful learning could not flow from a governance investigation into the circumstances of Mrs Creagan’s care. Such decisions appear to be incongruous with;
a. The inaccurate cause of death initially offered by the Trust,
b. The failure to investigate the seat of Mrs Creagan’s burgeoning infection after her pneumonia resolved.
c. The missed diagnosis of infective endocarditis,
d. The failure to monitor the development of Mrs Creagan’s heart failure during her inpatient treatment.