Hana Aisha Abd Elhamid · Prevention of Future Deaths report

On the 9th June 2014 I opened an investigation touching the death of Hana Aisha Abd Elhamid , 25 years old. The inquest concluded on the 7th May 2015. The conclusion of the inquest was “Narrative”, the medical cause of death was 1a Respiratory failure 1b Tracheal Stenosis complicating laryngotracheal injury sustained during self-extubation during treatment for a diabetic coma

Miss Abd Elhamid was a patient being treated for a mental health condition and it became necessary to treat her condition with Clozapine. It is likely that the diabetes was a complication of the use of Clozapine and routine fasting blood tests were not carried out which was a serious failure.

It is likely that the diabetes had been developing for some time before Miss Abd Elhamid became seriously unwell whilst on a home visit. Miss Abd Elhamid was taken to the hospital on the 13th November 2012.

There was a medical need to intubate Miss Abd Elhamid and during the process of waking Miss Abd Elhamid extubated herself. Although this is not unusual in these circumstances in this case the result was damage to the airway.

Many attempts were made to treat Miss Abd Elhamid at a specialist hospital where a tracheal stent was fitted.

Miss Abd Elhamid became unwell with breathing difficulties and was admitted to hospital on the 4th June 2014. A decision was taken to attempt to treat Miss Abd Elhamid which encountered such difficulties due to the narrowed airway that Miss Abd Elhamid died.

There was an opportunity to test for blood sugar which is likely to have demonstrated the presence of diabetes at a time where the diabetes would have been amenable to treatment. There was therefore an opportunity to render care which if taken would have prevented the death.

that this patient developed diabetes whilst on long term Clozapine treatment and that routine blood tests for sugar in the blood are likely to have prevented events, the need for intubation during treatment for a diabetic coma with resultant trachea injury following self -extubation, that directly led to the patients death