Marie Rollason
24 Feb 2016 · Coroner Zafar Siddique · Black Country
The coroner's concerns
1. loss of consciousness at home
“Evidence emerged during the inquest that Mrs [name redacted] had at least five periods of loss of consciousness at home by the time she visited her GP's Practice on ' the 23 December 2015”
2. missed opportunity for basic medical care
“When she was admitted back to the Hospital on the 23 December 2015, an ECG trace revealed an abnormality in the trace which can be indicative of changes that occur during a pulmonary embolism. However the Junior Doctor | recorded the ECG trace "was okay". She wasn't kept in for further observation | but instead discharged and advised that if the dizziness/fainting spells continue then she should be referred to a cardiologist via her GP”
3. failure in basic medical care
“The Consultant who gave evidence suggested that the ECG trace was a potential "Red flag' and he would have admitted her for further observation given that she had no previous cardiac related complaints and to try and understand the basis for her loss of consciousness. He went on to confirm in his opinion that on the balance of probability this was a failure in basic medical care”
4. potential preventable death
“had she been kept in Hospital and observed, then on the balance of probability it is more likely than not she may have survived. Further tests including the D- Dimer test could have been done to confirm the diagnosis and appropriate treatment commenced”