Kalma Ram-Henman
23 Oct 2018 · Coroner Veronica Hamilton-Deeley · Brighton and Hove
The coroner's concerns
1. dehydration due to inadequate fluid monitoring
“This lady arrived in A&E in a "precarious" state as the blood test results revealed and there were several failings”
2. hypokalemia and fluid deficit
“abnormalities likely associated with her low potassium level. This was not seen by the doctor who requested it. The signature on it is illegible. A second ECG should have been requested. It was not. She was written up for potassium in A&E as well as intravenous fluids but was given no potassium and only half a litre of intravenous fluids in her entire 24 hour admission”
3. missed fluid and electrolyte replacement
“Opportunities to realise that sodium and fluids had not been administered were missed overnight when Mrs RAM-HENMAN was transferred from A&E to Bristol Ward and was seen in the early hours of the 7th. It seems her notes were not read so the failure to give fluids and potassium was missed”
4. delayed treatment for electrolyte imbalance and condition
“On the morning of the 7th at around 10.30 am. the attending Doctor wanted Mrs RAM-HENMAN to be given Cyclazine, intravenous fluids and for her to have a CT scan. None of this was achieved before her death two hours later. She should have at least received the intravenous fluids and the Cyclazine. Again it seems that at this stage there was a failure to realise that she had not been given the Potassium she had been written up for in A&E”
5. inadequate laboratory monitoring
“Mrs RAM-HENMAN only had one set of bloods done. At Inquest I was told that she should have had more bloods for comparison. These would undoubtedly have shown her deteriorating condition and would have acted as an additional reminder of the failings in her care”
6. perforated gastric ulcer with suboptimal physiological optimisation
“It transpires that Mrs RAM-HENMAN had a large gastric ulcer which perforated. This in itself is a life threatening emergency and her presentation was unusual. From the evidence I heard it was clear that although there is no guarantee that she would have survived the perforation, had she been optimised in terms of fluids and Potassium her cardio vascular reserve would have been considerably better”