UK Inquiry Tracker

Raquel Harper

PFD Report Historic (No Identified Response) Ref: 2023-0192

Date of Report 13 June 2023

Coroner Nadia Persaud

Coroner Area East London

Response Deadline ✓ from report 7 August 2023

Hospital Death (Clinical Procedures and medical management) related deaths

Judiciary.uk Report PDF

No published response · Over 2 years old

Sent To

Barts Health NHS Foundation Trust

Response Status

Responses 0 of 1

56-Day Deadline 7 Aug 2023

Over 2 years old — no identified published response

About PFD responses

Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.

Source: Courts and Tribunals Judiciary

Coroner’s Concerns

1. There was a lack of thorough history taking and a number of assumptions were made on the basis of Raquel’s high BMI. There was an assumed chronic low oxygen saturation with no evidence that the doctors had checked the records available or asked the patient about her baseline. The oxygen saturations recorded in the Barts sleep apnoea clinic in 2015 and 2016 were noted to be 99% and 100%.

2. There was a lack of escalation of monitoring following the NEWS score of 10. It is of concern that the NEWS policy was not complied with by the nursing staff.

3. There was disagreement between senior clinicians as to how the Trust’s PE policy should have been applied. The policy is often not used in accordance with the specific wording. For example, the requirement for pleuritic chest pain is often ignored in practice. A senior clinician within the Trust considered that the caveat for pleuritic chest pain in the policy should be reviewed. In addition, the senior clinician described some of the wording in the policy as “clumsy”. In light of this, the Trust may wish to review the policy.

Report Sections

Investigation and Inquest

On the 26th July 2021 I commenced an investigation into the death of Raquel Mellonie Harper, aged 33 years. The investigation concluded at the end of the inquest on 2nd May 2023. The conclusion of the inquest was a narrative conclusion:

Raquel Harper died as a result of natural causes. Her death was however contributed to by an omission of hospital staff to carry out appropriate investigations and to instigate timely treatment for her pulmonary embolism.

Circumstances of the Death

Raquel Harper attended Whipps Cross Hospital on the 23 June 2021. She complained of a 5-day history of shortness of breath and difficulty breathing. Raquel had a low oxygen saturation, a high respiratory rate and a tachycardia. The assessing doctor used the pulmonary embolism rule out criteria (PERC), to rule out the likelihood of a pulmonary embolism causing her symptoms. The PERC test was positive, and a D Dimer should have been carried out. This was not done. A diagnosis of iron deficiency anaemia was made, based upon a low haemoglobin and low MCV level. Raquel was admitted to hospital and suffered from periods of desaturation requiring medical review and assessment. The diagnosis of iron deficiency anaemia was not re-visited and further investigations, such as arterial blood gases were not carried out. In the very early hours of 25 June 2021, Raquel became critically unwell. She required escalation of her care, but this was not provided until she was in a peri-arrest state at around 0330 on 25 June 2021. Raquel suffered a cardiac arrest at around 0400 and received resuscitation and thrombolysis. Sadly, there was no response to the emergency efforts and Raquel passed away at Whipps Cross Hospital on 25 June 2021. Had Raquel received the D Dimer test on the 23 June 2021, in accordance with the Trust's policy, this is likely to have triggered further investigations which would have resulted in a diagnosis of pulmonary embolism and a treatment dose of lower molecular weight heparin. On the balance of probabilities this would have prevented Raquel's death on the 25 June 2021.