Miscommunication between doctors at Queen’s Hospital contributed to the death of Collier Row mum-of-two, coroner rules

Walthamstow Coroner's Court. (Image: Archant)

A miscommunication between doctors at Queen’s Hospital contributed to the death of a Collier Row mum-of-two, an inquest heard.

Sarah Jane Bristow, 41, of Hillfoot Road, died of a brain haemorrhage after she fell down stairs at her friend’s house in Romford after drinking about a bottle of wine, Walthamstow Coroner’s Court was told on Friday, September 21.

When the nurse was taken to hospital there was a “terrible miscommunication” between Dr Aryan Rasheed – senior registrar – and Dr Dan Harris – consultant – which contributed to the death of Miss Bristow, the court heard.

Sarah – who was “very popular and a lot of fun” according to her sister – went to visit her friend Natalie Ward, on the night of Monday, July 18, 2016, in and they opened a couple of bottles of wine but Sarah was “shattered” and went to bed at about 7.30pm

At about 9pm, Natalie heard a noise and went to investigate.

She says she saw her friend fell “head over heels” down the stairs.

She landed with a thump and was not responsive.

Natalie called 999 straight away.

When the paramedic arrived Sarah was still lying in the hallway but was adamant that she did not want to go to hospital.

It was at this point that Natalie rang Sarah’s partner, Terry Ratcliffe, and asked him to come and help.

Terry told the court that when he arrived Sarah was asleep on the sofa and he had to wake her, and because she was refusing to go to hospital in the ambulance he decided to take her in his car.

According to a number of witness accounts, Sarah had no recollection of the fall.

Paramedic Lisa Nye was the first at the scene, and took down the first observations of Sarah.

She said there was no resistance from Sarah, and her level of consciousness on the Glasgow Coma Scale was recorded as 14 out of 15.

However, when she handed this over to the ambulance crew the information was taken down incorrectly, the court heard, and they wrote down that her level of consciousness was 15/15 – even though they had not assessed Sarah.

The ambulance crew arrived at Queen’s Hospital before Sarah and her partner Terry, and Ms Nye completed a verbal hand over to Dr Rasheed.

After hearing from the ambulance crew and Ms Nye, Dr Rasheed felt that a trauma call should be the next step – which would activate a number of specialist doctors – however because Sarah was not present he was unsure of what to do.

Shortly before 11pm he called for the help of Dr Harris, who took over.

Dr Harris assumed a clinical assessment had been carried out by Dr Rasheed – but it hadn’t – because Sarah had already been at the hospital for 30 minutes. He said this was a “very terrible miscommunication” and that he considered this was where everything went “badly and tragically wrong”.

The doctor thought he was deciding whether Ms Bristow was okay to leave the hospital and did not realise he was meant to carry out a full clinical assessment.

The court heard that Dr Harris was extremely busy, and that there were around 135 patients and seven doctors in A&E, and he was the only consultant.

Around 25 minutes later Dr Harris let Sarah and Terry leave the hospital, in what the coronor described as an “unwise decision”.

Sarah returned home with Terry, and when he woke in the morning he tried to wake her but he just got grunts.

He was not worried, as she was often difficult to rouse in the morning, so left her.

Sarah’s friend Natalie later went to check on her at 9.30am, and she felt that she was in a deep sleep and she spoke to Terry and they said to let her sleep.

Natalie then went back to check on her at around 3pm and Sarah had not moved so she called an ambulance.

Sarah was then rushed back to Queen’s Hospital, but she died of a bleed on the brain just a few hours later.

Senior Coroner, Nadia Persaud, was assisted throughout the inquest by Dr Stephen Metcalfe, of St Mary’s Hospital.

Dr Metcalfe confirmed Sarah’s case was a very unusual one, and considered that the LAS (London Ambulance Service) crew had shown the greatest effort to get the patient to hospital.

However he considered the care Sarah received in the emergency department at Queen’s was “not reasonable and sub-standard”.

Mr Ghosh – a consultant Neurosurgeon at Queen’s Hospital – stated that if Sarah had had a CT scan within eight hours of her fall, she would have survived.

Concluding, Nadia Persaud said: “Whilst the fall led to an intercerebral bleed, a failure to fully assess her in hospital, to ensure that all reasonable steps were taken to keep her in hospital and provide the care required, contributed to Sarah’s death.

“As such, a short form conclusion of accident would not be appropriate.

She added in her verbal conclusion: “Due to a miscommunication, the consultant erroneously believed that he was simply being asked to assess whether Ms Bristow could leave hospital without a full medical assessment.

“In light of this, the consultant carried out a relatively brief physical assessment and he assessed Ms Bristow’s capacity.

“From the findings of his clinical assessment and in view of Ms Bristow’s clear and vocal wish to leave the hospital, he allowed her to leave.

“There were no neurological observations taken and recorded in hospital.

“Ms Bristow and her partner were not encouraged to remain in the hospital for observations and for a CT scan.

“A CT scan should have been performed within eight hours.

“Had she received such encouragement, she is likely to have remained in the hospital, with the support of her partner.

“Had such observations and a CT scan been carried out, her death on July 20, 2016, is likely to have been avoided.”

Kathryn Halford, chief nurse, Barking, Havering and Redbridge NHS Trust: “As the Coroner’s report sets out, this sad case was complex, unusual and challenging, with lots of factors which ultimately resulted in Ms Bristow’s death. We have reflected closely as a Trust on the lessons we can learn, and how we provide the best possible care – despite the increasing challenges facing busy emergency departments like ours. Our thoughts are with Ms Bristow’s family and friends.”

* The Recorder would like to apologise to the family and all those affected by the error in the previous photo caption. The caption mentioned suicide - this was an error on our part. Suicide was not an issue with regards to the case and we are sorry for any distress caused.