Christina Lawal · Prevention of Future Deaths report

On 30 January 2019, Senior Coroner Mary Hassell commenced an investigation into the death of Christina Lawal aged 63 years. The investigation concluded at the end of the inquest which was conducted by me on 7 November 2019.

The conclusion of the inquest was that Miss Lawal’s death was due to natural causes.

The medical cause of death was:
1a acute myocardial infarction
1b coronary artery atherosclerosis
2 Type 2 diabetes mellitus

My short form conclusion was that “Miss Lawal had a myocardial infarction at her home on 23 January 2019. The infarction atypically presented as abdominal pain in the period before she went into cardiac arrest”.

Christina Lawal had type 2 diabetes with serious complications. She lived in Duncan Court which is an extra care sheltered housing scheme. She was a wheelchair user. She attended hospital for dialysis 3 times per week. On 23 January 2019, Ms Lawal attended dialysis and returned home around 6.30 pm. She informed staff that she was tired and that she was going to bed. At 7.20 pm she complained of stomach pain. Staff offered to call her an ambulance, Miss Lawal said that she would speak to the out of hours doctor. Miss Lawal spoke to the out of hours GP service and was advised to take Gaviscon. She was then left alone. At around 9.15 pm, Miss Lawal pulled the alarm cord in her flat. 2 staff members attended to find that she was vomiting and complaining of severe abdominal pain. One staff member returned to the office in order to make a 999 call to paramedics whilst the other remained with Miss Lawal. Miss Lawal’s pain increased which led to a further call being made to the ambulance service. Paramedics arrived shortly before 10 pm. Miss Lawal went into cardiac arrest shortly after their arrival. Attempts were made to resuscitate Miss Lawal using advanced life support measures. She was taken to the Royal London Hospital where her death was confirmed at 23.05.

1) The care worker had to return to the main office at Duncan Court in order to make a 999 call as there was no cordless telephone available for her use.

2) The emergency triage system used by the London Ambulance Service often involves the caller being asked to give information regarding the patient’s appearance (e.g. do they feel hot, are they sweating or clammy etc). Similarly callers may be asked to put questions to the patient regarding the nature and location pain. A caller may not give the correct information if they are not with the patient at the time of the call.

3) Callers to the ambulance service may not be aware of further deterioration in a patient’s condition if they are calling from a different location.