Chloe Hunt

“[the deceased] explained on 11 March 2022 in Accident & Emergency to the doctor her background of complex trauma and how difficult she found it to be in hospital. This was not factored into a plan for treatment.”

“Imaging established [the deceased] had swallowed 3 full-sized pens, 2 free in her stomach and 1 was impacted in her duodenum. There was a lack of consideration of the complexities of removal to guide whether the removal should be endoscopic or surgical. Endoscopy could not be converted into a procedure under anaesthetic in the interventional radiology suite.”

“The requirement for reintubation after each pen removal and the difficulty for a patient to tolerate multiple procedures without anaesthetic was not considered for [the deceased] on referral for removal, or whether this might need to be converted to a procedure under anaesthetic.”

“There was a lack of urgency in treating [the deceased] and lack of recognition of her deteriorating clinical condition.”

“[the deceased] was tachycardic throughout her admission with low blood pressure and there was no investigation of the underlying cause in a young otherwise physically healthy woman. NEWS Scores should not replace consideration of the whole clinical picture for a patient.”

“In the hours before [the deceased]'s death, she required oxygen for the first-time that was administered for approximately 75 minutes and [the deceased]'s heart rate reduced to normal for several hours for the first time in her admission. This reduction was not sustained, and her heart rated elevated later. These changes were not recognised as signs [the deceased] was a deteriorating patient”