Lisa Gale: Prevention of Future Deaths Report
Hospital Death (Clinical Procedures and medical management) related deaths
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Date of report: 11/11/2024
Ref: 2024-0619
Deceased name: Lisa Gale
Coroners name: Simon Fox
Coroners Area: Avon
Category: Hospital Death (Clinical Procedures and medical management) related deaths
This report is being sent to: Royal College of Pathologists | Royal College of Obstetricians and Gynaecologists | Chief Midwife | South West Regional Midwife | University Hospitals Bristol and Weston NHS Foundation Trust
| REGULATION 28 REPORT TO PREVENT FUTURE DEATHS | |
|---|---|
| THIS REPORT is BEING SENT TO: Royal College of Pathologists Royal College of Obstetricians and Gynaecologists Chief Midwife Southwest Regional Midwife University Hospitals Bristol and Weston NHS Foundation Trust | |
| 1 | CORONER I am Dr Simon Fox KC, Assistant Coroner for Area of Avon |
| 2 | CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made |
| 3 | INVESTIGATION and INQUEST On 20th April 2023 1 commenced an investigation into the death of Lisa Gale. The investigation concluded at the end of the inquest on 12th November 2024. The conclusion of the inquest was Natural Causes. |
| 4 | CIRCUMSTANCES OF THE DEATH Lisa developed a rare but serious condition of pregnancy Acute Fatty Liver of Pregnancy (AFLP). She attended hospital promptly and cooperated fully with the medical advice she received. Medical assessments and treatment were detailed and thorough. Despite this, and maximal therapy on intensive care, sadly she still died from this condition due to the rapid progression and severity of the AFLP and the added complication of acute pancreatitis. |
| 5 | CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows – (1) Blood was taken for liver function tests (LFTs) on admission before her condition was diagnosed; (2) Lisa’s LFT’s were grossly elevated (normal range in brackets) ALT 612 (10-50), bilirubin 122 (<21), creatinine 168 (45-84); (3) This was due to a potentially fatal condition Acute Fatty Liver of Pregnancy — from which she subsequently died; (4) Despite being grossly elevated, the results once obtained in the laboratory were not phoned through by the laboratory staff to the clinical staff; (5) This was because the Royal College of Pathologists’ guidelines for urgent reporting only provides for the same with levels above 750 for ALT, 300 for bilirubin and 354 for creatinine and does not provide for different reporting levels for those taken in pregnant women; (6) This is despite pregnancy specific conditions such as AFLP being potentially fatal at much lower levels of abnormal LFTs than those set currently by the Royal College of Pathologists; (7) As a result there was a delay in diagnosing her AFLP and starting appropriate treatment. |
| 6 | ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. |
| 7 | YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 10th January 2025. l, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. |
| 8 | COPIES and PUBLICATION I have sent a copy of my report to the chief coroner and to the following interested persons — a) Lisa’s family; b) University Hospitals Bristol and Weston NHS Foundation Trust. I have also sent it to [REDACTED] (Consultant Obstetrician) and [REDACTED] (Director of Midwifery and Nursing for Women’s Services) at University Hospitals Bristol and Weston NHS Foundation Trust who may find it useful or of interest. I am also under a duty to send the chief coroner a copy of your response. The chief coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the chief coroner. |
| 9 | 12th November 2024 Signature Dr Simon Fox KC, Assistant Coroner Area of Avon |