Angela Maguire · Prevention of Future Deaths report

On 22 April 2021 I commenced an investigation into the death of Angela Maguire, aged 84. The investigation concluded on 26 April 2022. The conclusion of the inquest was death due to natural causes, the medical cause of death being

1a Upper Gastrointestinal haemorrhage
1b Metastatic Cholangiocarcinoma

II Ischaemic heart disease, Atrial Fibrillation

Mrs Maguire became unwell and was referred to Queen Mary's hospital, London for a CT scan, performed on 31 March 2021. She then deteriorated and was taken by ambulance the following day to Kingston Hospital and admitted. Her symptoms suggested a malignancy, but this was not confirmed as the first scan was not accessed and a further CT scan was interpreted only partially. Additional tests were ongoing and clinical signs all supported the working diagnosis, so her supportive treatment was appropriate apart from a lack of senior oversight regarding her anticoagulation medication. On 7th April 2021 she began to display signs of an upper gastro-intestinal bleed, and she then deteriorated rapidly and died the following morning on 8th April in Kingston Hospital.

The clinicians assisting with the inquest advised the court that there was no system to share radiology across the Region. In West London, patients are frequently transferred from hospitals to access particular specialisms of care, such as cancer care. In this case, the previous images taken at Queen Mary's Hospital, London, could not be accessed across a common link by Kingston Hospital, Surrey and therefore the opportunity was missed to see and compare previous images. While this did not have an impact on the outcome in this case, it could have very significant consequences and lead to missed diagnoses and potentially fatal outcomes of untreated disease processes. In this case the opportunity to offer palliative care and ease the relatives of end of life treatment was lost. The lack of a shared portal also creates further work for clinicians who have to contact the previous hospitals to access this information.

There are many shared systems in place in the NHS for cross-site sharing of images and reports, and it was not clear from those assisting the court at this inquest why similar systems are not currently in place for this Region and not anticipated for “several more years”.