_ 1_ The London Ambulance Service (LAS) emergency operations centre (EOC) made a pre hospital alert telephone call to the Whittington Hospital emergency department, regarding the expected arrival eight minutes later of patlent in respiratory arrest This was good practice. However, failed t0 include in that alert the information that Ms Choya was pregnant This was a crucial detail, which had been passed to the LAS at the very outset by her husband, and then again to the EOC by the emergency medical crew on scene. 2_ On arrival at the Whittington Hospital, the detail of the pregnancy was not communicated effectively: It is unclear whether the LAS crew did not mention the fact, or whether the emergency staff simply did not hear it: In any event, it took 16 minutes post arrival for the pregnancy to be recognised and the obstetric team to be called.
3. Without the obstetric team, the emergency department team focus was on the potential for a pulmonary embolism, and alteplase was given: Only later was a scan conducted and free fluid noted_ By the time of the laparotomy it was too late to save Ms Choya. ACTION SHOULD BE TAKEN In my opinion, action should be taken to prevent future deaths and believe that you have the power to take such action. they

YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report; namely by 30 September 2019. 1, the coroner; may extend the period: response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise must explain why no action is proposed: