An inquest into the death of a 60-year-old mother-of-five and grandmother-of-twelve found that a catalogue of failings in her care at Whipps Cross Hospital led to her death

By Marco Marcelline

“Gross failings” in the care of a Walthamstow woman while at Whipps Cross Hospital amounted to “neglect” and led to her untimely death, a coroner has found.

The inquest concluded that Sultana Razia Choudhury, 60, sustained an accidental injury caused by a kidney biopsy undertaken at Royal London Hospital on 7th December 2022. After being sent home following the biopsy, Sultana attended the A&E department at Whipps Cross Hospital in “excruciating pain” that was “worse than childbirth” from symptoms caused by the kidney injury on 14th December 2022.

Senior Coroner for City of London Graeme Irvine found that a catalogue of failings in her care at Whipps Cross amounted to neglect and contributed to her death on 17th December 2022 from a cardiac arrest following a catastrophic internal bleed.

Mr Ivine identified three key areas of failures during her care: the failure by trust staff responsible for her care to identify a serious renal haemorrhage, the failure to adequately monitor Sultana over the weekend, and the prescription of the blood-clot stopping and blood-thinning drug enoxaparin to a patient with an active renal bleed. 

The court heard how Sultana, who lived in Walthamstow, had been in “pretty good health” before developing diabetes and a kidney problem as she got older.

Her family told the inquest that a doctor convinced her to do kidney biopsy for the purposes of clinical research which could help others. She was told that although it could help her in the future, it was not something that was needed for investigation or treatment of her condition. Knowing this, Sultana agreed to undertake the biopsy. 

A week after the biopsy Sultana attended A&E at Whipps Cross and was then admitted after noting blood in her urine. Over the next few days, tests were carried out and Sultana was given morphine and stronger pain killers, before being told that she needed a blood transfusion.

Scans and tests taken at Whipps Cross failed to reveal that she was suffering a “significant” renal bleed, and she was instead diagnosed with a bacterial urine infection.

The court heard how following Sultana’s death Whipps Cross Hospital produced a Serious Incident Report (SI) which Mr Irvine described as “relatively damning”. 

The report highlighted three failings during Sultana’s stay at Whipps Cross Hospital. The first was the misdiagnosis of Sultana with a urine infection and the failure of anyone to grasp that she was suffering from a significant and dangerous bleed from her kidney following the biopsy. The second was that Sultana’s care over the weekend was poor and there were missed opportunities to take a closer look at what lay behind her deterioration.

The third was that no-one grasped that she was being given a medication which no one should be given when suffering from an active internal bleed, and which would have made the bleed more harmful to her.

During the hearing Mr Irvine said that the “failure to properly police” the use of blood-clot stopping and blood-thinning drug enoxaparin in Sultana’s care was part of a “recurring theme” of a “lack of curiosity” among NHS professionals while prescribing drugs for patients.

Mr Irvine also pointed to a “lack of focus or awareness about what the likely causes of her presentation were” and said that doctors in charge of her care should have considered Sultana’s biopsy in an investigation into  whether she was suffering a significant bleed. This, had it happened,  “could have saved her life”, he said.

Following the inquest Sultana’s family said:  “Our mum was married for nearly 50 years, she had five children and 12 grandchildren. She had a humble upbringing, born and raised in Dhaka, Bangladesh. She was the oldest of four children and lived through the Bangladesh liberation war before completing secondary school and then marrying my father at the age of 17.”

“The loss of our mum, who was known as a ‘mum’ to everyone, has left a huge hole in our family. We are grateful to the coroner that her death was thoroughly looked into and the many problems in her care identified.

“It’s ironic that she did this biopsy as she was convinced that this would contribute to clinical research, and it would be impactful in helping improve the treatment and wellbeing of others. This is the sole reason why she did it; she had no other reason to. Ultimately, this decision is what lead to her death. She passed away just as she lived – trying to help others.”

Frankie Rhodes, solicitor at law firm Leigh Day, added: “The coroner’s finding of neglect, along with issuing a Prevention of Future Deaths report, reinforces the legitimate concerns Sultana’s family had with their mother’s care and goes some way towards reassuring them that these mistakes will not be repeated. It was shocking to hear staff at the defendant trust admit to issues with diagnostic overshadowing, confirmation bias, medication errors and the failure to do a simple CT scan. 

There were multiple opportunities for staff at the trust to have identified that Sultana was bleeding from her kidney and to have treated her injury accordingly. It is even more worrying to hear that the coroner has identified a pattern of similar mistakes being made and the recommendations for improvement not being implemented within trusts in East London. We can only hope that the findings in this inquest act as a vehicle for much needed change.”

Mr Irvine stated he has concerns that the same failings documented during the hearing could happen again at Barts Health NHS Trust, which runs Whipps Cross. He said he will be writing a Prevention of Future Deaths report to highlight his concerns which will be sent to the trust and to the Department of Health and Social Care. 

Barts Health NHS Trust accepted during the inquest that if different care had been provided to Sultana that there was an opportunity to save her life.

A spokesperson for Barts Health NHS Trust said: “We express our deepest sympathies to the family of Ms Choudhury and we apologise that in this instance, the care we provided did not meet the standards we set ourselves.  

“We have taken learnings from this case to make sure we maintain these standards and prevent this happening again.”  

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