An inquest has concluded that the death of 24-year-old Clarissa Street resulted from serious failings in her medical care, finding that she would have survived had she received appropriate treatment.
On 13 August 2024, Clarissa, who had a known history of pulmonary embolism (PE), was taken to A&E by ambulance after developing severe symptoms including breathlessness, chest pain, and a collapse with loss of consciousness. During triage, the seriousness of her condition was not recognised or escalated, despite a National Early Warning Score (NEWS) of eight, indicating that she was critically ill, and despite her partner advising staff that she had a history of pulmonary embolism and that he was extremely concerned about her presentation.
Clarissa was left in a corridor late at night without medical oversight or regular observations, and given an oxygen mask that was not connected to an oxygen supply. This was inappropriate practice, provided no clinical benefit and was based on the mistaken assumption (despite the NEWS score) that she was hyperventilating.
When she was reviewed, belatedly, by an ED doctor, that doctor failed to obtain the written notes (including a copy of an ECG which had been undertaken) or take a full history, despite Clarissa’s partner having informed staff of her previous PE. The doctor also misinterpreted a bedside cardiac monitor. As a result of these failures, the doctor incorrectly concluded that she was suffering from supraventricular tachycardia. This misdiagnosis led to inappropriate vagal manoeuvres being performed in an attempt to reduce her heart rate.
These manoeuvres caused a cardiac arrest, which in turn caused multiple further arrests despite repeated resuscitation. Clarissa died shortly afterwards as a result. It was concluded that she would not have died had the vagal manoeuvres not been performed.
Michael was instructed by Jenny Fraser of Fosters Solicitors.
