FIONA MARGARET PATRICIA LEWIS · Prevention of Future Deaths report

On the 8th of April 2015, I resumed the inquest into the death of FIONA MARGARET PATRICIA LEWIS. The conclusion at the end of inquest was that the death was due to Natural Causes, however there were circumstances in respect of this very sad death that gave rise to concern.

Fiona Luis was admitted to Ipswich Hospital on the 5th of September 2014 following a three week period of symptoms which had initially suggested a possible orthopaedic problem, although there was then concern that there was an underlying neurological component to her condition. There were clearly difficulties in obtaining a clinical diagnosis for the condition in life, which were looked into at the inquest given her son’s concerns here, but her condition sadly deteriorated and she passed away at Ipswich Hospital on the 13th of September 2014. By that time an underlying malignancy was suspected but not proven, and the cause of death was found by an independent pathologist to be from Disseminated Carcinoma. No primary mass could be identified at post mortem examination. Medical management and diagnostic issues were explored at the inquest, as stated above. There were, however, concerns raised after the death by one of the nursing staff that health care professionals working on the ward had failed to initiate prompt resuscitation following the collapse, despite Fiona Luis still being for resuscitation in the event of a collapse occurring, and that, once the problem was recognised, appropriate knowledge or ability in respect of resuscitation was not displayed by those health care professionals. These matters were explored at the inquest, but there was evidence that it was unlikely that failure of prompt resuscitation would have altered the outcome here in view of CSF involvement by tumour.

Although, in the very sad circumstances of the death of Fiona Luis, any problems in respect of resuscitation at the time of the collapse are unlikely to have affected the outcome for the reasons given above, it is clearly important that there is confidence that health care professionals involved with patient care are adequately trained in resuscitation and able to respond appropriately in the event of a collapse occurring.