3:00 PM August 30, 2022
4:06 PM August 30, 2022
A Hornchurch woman’s sudden death from an undiagnosed heart condition exposed “unacceptable” record-keeping at an east London NHS trust.
Coroner Graeme Irvine said the death of 32-year-old Gift Agwuncha was a “tragedy” and “absolutely heart-breaking”.
He gave the Barking, Havering and Redbridge University Hospitals NHS Trust (BHRUT) four weeks to assure him it had fixed administrative problems.
The trust has apologised.
Mrs Agwuncha died at her home in Leathert Close on April 20, 2021.
A post-mortem by Dr Elizabeth Soilleux found a build-up of fatty deposits in her arteries which, combined with a likely blood clot, had affected her heart.
One artery was 90 per cent blocked. Others were 60-70pc blocked.
Six months earlier, Mrs Agwuncha was hospitalised for a clot on the lungs, which was thought to have been caused by taking the combined contraceptive pill.
An inquest at the East London Coroner’s Court in Barking last week investigated whether further investigation could have prevented her death.
Mrs Agwuncha should have had a blood test before an appointment in March 2021, but it was never done.
Consultant haematologist Dr Serajul Islam testified that she should have been sent forms to book her test.
But when asked if they had definitely been sent, Dr Islam said BHRUT had not recorded whether forms were sent to patients.
Coroner Graeme Irvine said that was “remarkable”.
“It seems to me that that is a very, very surprising and unacceptable set of circumstances to find ourselves in, that the trust can’t say with any degree of certainty that such important documentation was sent to Gift,” he said.
He gave BHRUT 28 days to explain “how it’s going to resolve that situation in the future”.
But while the tests might have found evidence of Mrs Agwuncha’s condition, Mr Irvine did not find this would have saved her life.
Dr Islam and Dr Soilleux testified that even if the tests had triggered further investigation, treatment would not have occurred in time.
Chief medical officer Mamta Shetty Vaidya said BHRUT will answer the coroner as ordered.
“We would like to offer our condolences to Mrs Agwuncha’s family and we’re sorry she didn’t always receive the high quality of care she was entitled to at our hospital,” she said.