Miss C · Prevention of Future Deaths report

On 13 October 2021 I commenced an investigation into the death of Miss C, aged 36. The investigation concluded at the end of the inquest on 24 August 2023. The conclusion of the inquest was that:

Miss C died at Northampton General Hospital on 5th October 2021. The primary underlying causes are recent weight loss with nutritional deficiencies and interstitial pneumonia. On 4th October 2021 during her deterioration, a doctor should have reviewed but did not do so until later. A review before the cardiac arrest would have provided a chance for enhanced supportive care and an early peri-arrest call might have been activated which could have had a favourable effect on the outcome. There was therefore a missed opportunity in the medical care.

Miss C died at Northampton General Hospital on 5th October 2021. The primary underlying causes are recent weight loss with nutritional deficiencies and interstitial pneumonia. On 4th October 2021 during her deterioration, a doctor should have reviewed but did not do so until later. A review before the cardiac arrest would have provided a chance for enhanced supportive care and an early peri-arrest call might have been activated which could have had a favourable effect on the outcome. There was therefore a missed opportunity in the medical care.

Although ultimately determined to be non-causative of the death, the management of the cardiac arrest which occurred around 7 hours before Miss C passed away was scrutinised. During the cardiac arrest, an arterial blood gas showed metabolic acidosis, hyperkalaemia, increased lactate, hyponatraemia, and hypoglycaemia. Calcium gluconate (dose not known) and 20% glucose were administered. Administering calcium gluconate (medication used to manage hypocalcaemia) is not the Hospital Trust’s policy for the treatment of hyperkalaemia in cardiac arrest.

There were conflicting amounts of dextrose recorded as given in the clinical notes compared to what was agreed on the drug chart. The drug chart states that only 500mls of 5% glucose was commenced at 17:20 hours, however the clinical notes state that the following was given:

• 20% 100mls,

• 3 bags of 5% Dextrose.

Insulin was not given. The Hospital Investigation Panel concluded that dextrose and insulin would be administered to treat hyperkalaemia however, as Miss C was hypoglycaemic (blood sugar of 0.9mmol/l) and this would have further reduced her blood sugar, this was the rationale for not administering insulin at that time.

Return of spontaneous circulation was achieved after ten minutes.

Resuscitation Council UK and NGH NHS Trust should consider a review of their policy in relation to the out of hours availability of Resuscitation Officers.