A Hornchurch family said the “apple of their eye” should still be alive, after a coroner ruled that she received “inadequate” treatment at Queen’s Hospital A&E days before her death.
Daisy Lyons, who had complex needs meaning she was entirely reliant on family and carers, was taken to the Romford hospital with a severe and persistent cough on December 28 last year.
It took three hours for her to be seen before she was discharged home with a prescription of Piriton and codeine syrup, an inquest heard.
Five days later, the 31-year-old stopped breathing due to a severe chest infection. She died on January 2 when treatment was withdrawn.
After hearing evidence from Queen’s Hospital doctors at East London Coroner’s Court on Friday (August 14), Dr Shirley Radcliffe concluded that “too many small things went wrong which resulted in the death of Daisy”.
The coroner said the treatment Daisy received at A&E was “inadequate” and that she should have been admitted for further treatment rather than discharged the same day.
“If she had been admitted, expert opinion was that it was more likely she would have not died at Queen’s Hospital on January 2,” Dr Radcliffe said.
Daisy’s parents, Sandra and Terry, had always asserted that her death was preventable.
Sandra felt Daisy’s mental and physical handicaps meant she was always at the "bottom of the food chain" at the A&E.
Terry added that it became clear to them over the years that A&E doctors were uncomfortable dealing with someone who was non-verbal.
He said: "She should still be here now, laughing and giggling, sitting on the patio and enjoying the sunshine."
Terry said he hopes Daisy’s death will prompt change to how people with complex needs are treated at A&E departments.
Daisy had a history of severe learning disabilities, scoliosis, dysphagia, and repaired congenital heart conditions.
She was non-verbal and was wheelchair dependent.
Despite this, for much of her life Daisy was "happy and healthy," Sandra said.
She travelled the world, loved swimming and going to the cinema, theatre, or fairgrounds.
Sandra said: "She was the apple of everyone's eye. I've never met anyone more loved.
"She will be missed more than can ever be explained."
The inquest heard from three witnesses from Barking, Havering and Redbridge University Hospitals NHS Trust - which runs Queen's - and independent expert Professor Jerry Nolan who is consultant in anaesthesia and intensive care medicine.
Daisy’s parents took her to an out-of-hours GP as she’d had a persistent cough for several days.
They were advised to take her to A&E, where after a long wait to be seen a chest X-ray was assessed as showing no signs of infection.
Professor Nolan confirmed that signs of infection were not present on the X-ray, but pointed out that there is often a lag between the onset of infection and when it is visible on an X-ray.
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Her oxygen levels were significantly lower than her baseline and her cardon dioxide levels were twice as high, the inquest heard.
Despite this, and the fact that she was a high-risk patient due to breathing difficulties inherent with scoliosis, she was discharged.
Professor Nolan’s opinion on the balance of probabilities was that if she hadn’t been discharged, Daisy would not have died when she did, though he added this may have been the beginning of a downward spiral regardless.
Dr Radcliffe issued a narrative verdict, concluding that there were inadequacies in how Daisy was assessed, treated and discharged on December 28.
Andrew Deaner, BHRUT's chief medical officer, said: “I am sorry Daisy did not receive the care she should have in our hospital, and I would like to apologise again to her family for the distress we have caused them.
“Since Daisy’s death we’ve implemented robust staff training on recording patient observations, to ensure discharge observations are taken and escalated when there is a concern, and we have taken further steps to improve care for patients with learning disabilities.”
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