Sarah YOUNG · Prevention of Future Deaths report

On 30 April 2019 I commenced an Investigation into the death of Sarah YOUNG aged 34. The investigation concluded at the end of the Inquest on 28 January 2020. The conclusion of the Inquest was a Narrative Conclusion: The Deceased died from an extensive cerebral sinus thrombosis; the delay in her receiving the appropriate medical treatment may have reduced her chances of survival but could not be said to have contributed to her death.

The medical cause of death was:

Ia Bilateral Venous Infarction
Ib Cerebral Venous Sinus Thrombosis

On 9 April 2019, after suffering with headaches for 2 days, the Deceased was admitted by ambulance to Bedford Hospital with increasing confusion, immobility and fluctuating levels of consciousness. Following her arrival at the Emergency Department at 16.43 hours, she underwent a CT head scan. The Neurosurgical Team were contacted and advised that, as there was a suspicion of a venous sinus thrombosis, she should also have a CT venogram and receive a neurological review. Although she subsequently required care under the Intensive Care Unit and underwent a CT venogram at 21.28 hours, she did not receive a neurological review until 16.15 hours on 10 April 2019; the neurological review resulted in advice to start her on intravenous heparin which was commenced at 17.17 hours that same day. Her condition did not improve and she was declared to have suffered brain-stem death at 12.30 hours on 12 April 2019. Although earlier treatment with intravenous heparin could have increased her chances
survival, the medical opinion available at the Inquest was that it would not have prevented her death.

(1) Although Sarah was referred to the Medical Team at 20:00 on 9 April 2019 whilst she still in the Emergency Department awaiting the CT venogram, she was never seen by them. The evidence to the Inquest from the Medical Registrar on call that evening was that “if a decision to admit to ITU is made, an immediate or urgent medical review is not required, as the patient is under the direct care of the ITU team” yet the evidence from one of the ITU Consultants in charge of her care was that the ITU Team do rely on the Medical Team to assist in progressing a diagnosis( including involving a Neurologist where required) and that it was a matter of regret for him that there had not been more Medical advice in this case;
(2) Although the Neurosurgical Team had advised the Bedford Emergency Department Team at 19.45 hours on 9 April 2019 that a Neurological opinion should be sought alongside the CT venogram, such opinion was not sought until 16.15 hours on 10 April 2019 (the following day) and, even then, only after further prompting from the Neurosurgical Team. The Inquest heard that a Neurological opinion was likely to have involved immediate consultation with the on-call Neuroradiologist which would have resulted in a much earlier diagnosis and treatment of the Cerebral Venous Sinus Thrombosis;
(3) The Inquest heard that referrals to the Bedford Neurologist (only available during Monday - Friday working hours) are not always picked up through the standard referral system and often require personal 1:1 contact between clinicians.