Hayley Christine Clark · Prevention of Future Deaths report

On 27/05/2015 I commenced an investigation into the death of Hayley Christine Clark, 36. The investigation concluded at the end of the inquest on 12 April 2016. The conclusion of the inquest was a Narrative conclusion as follows: Hayley Christine Clark died, at Rotherham Hospital, on 24th May 2015, from the effects of severe malnutrition. Her malnutrition arose from a combination of factors, which did not include anorexia, but which did include poor eating discipline due, in part, to longstanding abdominal discomfort. The cause of death was
1a. Respiratory failure, 1b Pulmonary oedema, 1c Severe multi-factorial malnutrition,
2. Acute pyelonephritis, electrolyte imbalance, anaemia and immune deficiency

1. Hayley Christine Clark was a 36 years old female with a medical background which included long term malnutrition, hypogammaglobulinemia, irritable bowel syndrome, anaemia and depression.

2. She was admitted to Rotherham General Hospital on 12th May 2015 with electrolyte imbalance.

3. As part of a standard package of pain management, Ms Clark received Paracetamol. However the dose administered was the standard adult one and had not been adjusted to reflect Ms Clark’s extremely low (less than 50kg) body weight. This overdose of Paracetamol caused derangement of Ms Clark’s liver function. The problem was identified, the Paracetamol was withdrawn and Parvolex was administered.

4. Ms Clark’s condition deteriorated. She was transferred to the High Dependency Unit on 22nd May 2015 and she died on 24th May 2015. The cause of her death was as set out above.

(1) There was a failure, on the part of the staff who prescribed and administered the Paracetamol to Ms Clark, to recognise the need to adjust the dosage (in evidence the required reduction was said to be 50%) to reflect Ms Clark’s extremely low body weight.