Christine Goodfriday Nakaefeero · Prevention of Future Deaths report

On 22nd June 2022 this Court commenced an investigation into the death of Christine Nakaefeero, age 56 years. The investigation concluded at the end of the inquest between 20th and 21st July 2023. The court returned a narrative conclusion.

“Christine Goodfriday Nakaefeero died at home on 21st June 2022 due to a pulmonary embolism caused by a deep vein thrombosis ("DVT"). The DVT was made more likely by: a medical condition, uterine fibroids and the treatment for that condition, tranexamic acid.

In 2019 Ms Nakaefeero was referred to the gynaecology clinic with a recommendation that she underwent a hysterectomy to effectively treat her uterine fibroids. Due to a breakdown of communication between Ms Nakaefeero and the Trust, the surgery was not undertaken. Had the surgery taken place, Ms Nakaefeero would probably not have developed a pulmonary embolism in June 2022.”

Ms Nakaefeero’s medical cause of death was determined as:

1a Pulmonary Emboli; 1b Deep Vein Thrombosis; II Uterine Fibroids

Christine Goodfriday Nakaefeero was found unresponsive at home on the evening of 21st June 2022. Despite the best efforts of her family and emergency services she was declared deceased that evening.

Her death was caused by a pulmonary embolism, in turn caused by a deep vein thrombosis.

Earlier that day Ms Nakaefeero had been discharged from hospital having presented with symptoms of menorrhagia and associated pain and anaemia on 19th June 2022.

Whilst an inpatient, Ms Nakaefeero was assessed for risk of venous-thrombo-embolism (“VTE”) risk utilising the Trust’s VTE policy, she was categorised as having zero risk of thrombo-embolism.

Ms Nakaefeero had been diagnosed with uterine fibroids since 2019 and had been prescribed tranexamic acid and pain relief to control the symptoms.

1. Ms Nakaefeero was assessed at a Gynae-oncology clinic in early 2019. The patient was diagnosed as not suffering from any form of cancer and was therefore referred on to the “benign” gynaeology team.

Ms Nakaefeero was advised that it was likely that the most effective treatment for her condition was a hysterectomy. It was expected that the likely wait for this treatment would be 6 months.

Ms Nakaefeero was not allocated an appointment and therefore had not received the necessary surgery by the time of her death in June 2022. Had the surgery been undertaken it is probable that she would not have developed a pulmonary embolism.

Although the trust has investigated these circumstances and implemented change, no clear explanation could be offered for why the deceased slipped out of this care pathway. I am not satisfied that the risk of re-occurrence has been properly addressed.

2. The clinicians treating Ms Nakaefeero assessed her VTE risk utilising an established algorithm based on national guidance. The assessment was undertaken appropriately but it failed to identify two risk factors which made the formation of a DVT more likely, namely, large uterine fibroids and the use of tranexamic acid. I have concerns that the omission of these factors in the assessment criteria limited the effectiveness of the risk assessment.