In this inquest the coroner made a finding that the cumulative failings of the Hospital Trust in the prescription and management of post-operative anticoagulation, and acting on imaging were sufficient in combination to amount to neglect.
Mrs Alcantara died aged 65yrs on 04/06/2024 at The National Hospital for Neurology and Neurosurgery in Queen Square, London following surgery to remove a benign acoustic schwannoma tumour. Surgery was complicated by postoperative cerebral venous sinus thrombosis (CVST) which was not adequately investigated, diagnosed or treated (with appropriate anticoagulation) in timely fashion.
It was submitted on behalf of the family that the acts/omissions of hospital staff sufficient to warrant a finding of neglect included the following:
- Failing to prescribe and administer appropriate anticoagulation medication in accordance with a clearly documented plan.
- Documenting medication as having been given when it had not been.
- Failing to read and act upon the recommendations of a neuroradiologist.
- Failing to investigate, diagnose and treat CVST in timely fashion.
Facts:
Mrs Alcantara was admitted to the Hospital on 21/05/2024 and underwent tumour resection surgery. Surgery was deemed a success and post operative prophylactic anticoagulation (in the form of low molecular weight heparin [“LMWH”]) was directed from 48 hours (on 23/05/2024) to prevent clot formation. Despite being recorded as given, LMWH was not commenced.
On the morning of Friday 24/05/2024 an MRI was performed and reported by a consultant neuroradiologist. An area of slow blood flow was identified in the right sigmoid sinus and a CT venogram to exclude thrombus was recommended.
The report was neither read nor acted upon by senior clinicians, no CT venogram was requested or performed and the CVST went undiagnosed.
It was accepted by trust clinicians that the CT venogram should have been performed and LMWH commenced on 24-25/05/2025.
In the early hours of 27/05/2025 Mrs Alcantara suffered a severe clinical decline and underwent surgery to insert and an extra ventricular drain [EVD] and an intracranial pressure [ICP] monitor.
A CT venogram on 27/05/2024 confirmed complete occlusion of the right transverse sinus and sigmoid sinus. It was evident that the CVST suspected on 24.05.2024 had progressed/extended to the point of complete occlusion on 27/05/2024, resulting in brain haemorrhage with devastating consequences.
Treatment dose LMWH was commenced later that day. Despite further surgical interventions, having suffered catastrophic brain injury and in a significantly weakened state, Mrs Alcantara developed hospital acquired pneumonia and sepsis. On 04.06.2024 the decision was made to withdraw life support and she died.
At the inquest clinicians responsible for care accepted that if prophylactic anticoagulation had been administered it probably would have had a material impact on the development / extension of the CVST.
The Trust clinicians also accepted that timely treatment dose LMWH would probably have prevented the further extension of the thrombus, and death on 04.06.2024 would have been avoided.
Neglect:
The Coroner highlighted that “Neglect” was a significant conclusion, or “rider” to a conclusion, to reach. He stated that it reflects a low standard of care. He had to decide whether the identified failings constituted a “gross failure” and in so doing had to ask himself what this means. He emphasised that an important factor in determining whether the identified failings were “gross” was to consider the cumulative consequence of any acts or omissions.
In his view the cumulative failings were sufficient in combination to amount to neglect.
He held that the lack of heparin prescription both from the prophylactic and therapeutic perspective contributed to her death. In particular, her death was contributed to by absence of treatment dose heparin which should have been administered following the CT venogram request.
Conclusion:
The Coroner concluded that Mrs Alcantara died from the consequences of CVST which occurred after necessary surgical treatment. There were multiple missed opportunities to act on imaging, which highlighted this potential diagnosis and also to initiate medication, which would likely have slowed the progression of the thrombosis and prevented her death on 04/06/2024. In his view the combined consequences of these missed opportunities amounted to neglect, which contributed to her death.
Rory Badenoch, was instructed by Amy Anderson of Russell Cooke solicitors. The inquest took place on 7 March 2025 at St Pancras Coroner’s Court before HM Assistant Coroner Dr Richard Brittain.
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