Coroner’s warning after patient death

Report by Russell Hargrave

Whipps Cross University Hospital

Whipps Cross University Hospital

Patient safety is at risk because of a shortage of neurologists at Whipps Cross University Hospital, an inquest into the death of a patient concluded.

Marina Fagan, a 51 year-old mother of four from Chingford, died from a rare neurological condition in October 2015. A coroner’s report into her death identified several missed opportunities to diagnose Marina, who attended Whipps Cross on 17th September complaining of severe headaches.

No neurologist was on-call at the time Marina was first admitted to hospital, according to the specialist who eventually treated her. He also told the inquest of his concerns there were too few neurologists locally to guarantee patient care.

Marina received a neurological examination when first admitted, but was discharged from Whipps Cross in Leytonstone after two days when no abnormalities were found. She returned to the hospital when her symptoms worsened later the same day, and again five days later, but no MRI scan was taken until 30th September. The scan found that Marina suffered from the rare and untreatable condition Posterior Reversable Encephalopathy Syndrome, and she died on 6th October.

Concerns about local provision of neurological care were also raised by Marina’s doctor, who told the inquest the current waiting time to see a neurologist in the outpatient unit is 72 days.

The coroner concluded that although Marina’s condition would not have been treatable, it could have been diagnosed earlier.

Hodge Jones & Allen, the legal firm representing Marina, said in a statement on behalf of her family: “Mrs Fagan’s family are hugely concerned about the time it took the hospital to diagnose such a severe and life-threatening condition. Mrs Fagan continually presented at Whipps Cross with extreme and persistent headaches, yet she was not seen by a specialist neurologist or given an MRI scan. It is clear from the coroner’s report her case raises significant concerns about the shortage of neurologist cover. It is hoped Barts NHS Trust will take immediate steps to address this serious issue.”

A spokesperson for Barts Health Trust, which runs Whipps Cross, said: “We are deeply sorry that Mrs Fagan was not seen by a neurologist sooner, although the coroner found that it is unlikely that an earlier diagnosis would have prevented her death.

“Along with the rest of the country we have a low number of neurologists. We look forward to welcoming an additional neurologist in August, and in recognition of the challenges we are exploring how we can work more effectively for the safety of our patients.

“In the meantime we are meeting the waiting time standard we are set nationally for appointments and continue to share resources across our hospitals to ensure that patients can be seen by our neurology team if necessary.”

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