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Inquest into the death of nurse Mary Agyapong, aged 28

A Coroner has delivered a narrative verdict into the death of nurse, Mary Agyapong, who died aged 28 of multi organ failure and Covid-19 and urged the Prime Minister to hold an inquiry into the pandemic "as soon as is practicable".

Posted on 30 March 2021

At the conclusion of an inquest at Luton and Bedfordshire Coroners Court Coroner Emma Whitting said: “Mary died after contracting Covid-19 but it remained unclear where and when her exposure to the virus had occurred.”

Mary died at the start of the first wave of the pandemic, five days after the birth of her daughter by emergency caesarean section at Luton and Dunstable Hospital.

Mary had attended Luton and Dunstable hospital, where she worked, on April 5, 2020, “breathless, exhausted and weak”, her husband Ernest Boateng told the inquest. She was tested for covid and was discharged.

Ernest said: “When I saw her, she looked absolutely appalling. I could not believe that she had been discharged from the hospital in her state, as she was so poorly.”

Two days later, at midnight, when Mary was struggling to breathe, Ernest called for an ambulance, which arrived two and a half hours later. He was not able to accompany Mary to the hospital because of covid restrictions.

It was decided to deliver the baby by caesarean, and Ernest had to wait in the hospital car park. Baby Mary was transferred to the premature baby unit and her mother was taken to the intensive care unit where her breathing deteriorated to such an extent that she required sedation and intubation. Mary was not able to hold her baby due to Covid.

Ernest said: “I was getting more and more anxious at the fact that both Mary and my new-born daughter were alone and I felt helpless that I could not see or comfort either of them.”

In the early morning of 12 April Ernest was told by telephone that Mary was expected to die. By the time Ernest arrived at the hospital, Mary had already died.

Medical staff told the inquest they were content that adequate care had been given to the patient, and that her condition was properly monitored throughout her time in hospital.

Ernest said: “I have real concerns about Mary working whilst heavily pregnant in such a very stressful and in my view risky situation.”

He said that following Mary’s death, other clinicians told him they had raised concerns about safety at work and lack of protective equipment available to frontline staff in the midst of the pandemic.

He added: “The death of someone you love is always sad, but the shocking way in which Mary died is something we will live with for the rest of our lives. I do not want Mary to die in vain and hope that changes can be made to ensure that all women who reach 20 weeks of pregnancy be allowed to work from home or be suspended on full pay. As no family should ever have to go through what I have.”

At the conclusion of the inquest into Mary’s death, the coroner said:

“After collapsing at home on the morning of 5 April 2020 when 35 weeks pregnant with her second child, the Deceased was diagnosed with suspected Covid-19 at the A&E department of the Luton & Dunstable Hospital where she was employed as a Senior Nurse.

“She was discharged the same day but, following a deterioration at home and a further assessment in the same A&E department in the early hours of 7 April 2020, she was admitted to the Labour Ward.

“She was the hospital’s first pregnant patient with suspected Covid-19. A decision was taken to deliver her baby by caesarean section which was successfully performed at 23.41 hours that night; however, her condition did not improve and by the following morning she was requiring increasing levels of oxygen.

“A Respiratory review at 13.25 hours on 8 April 2020 concluded that she was showing signs of severe Covid-19 pneumonia and, following a sudden deterioration at around 15.00-15.30 hours, this was confirmed by chest x-ray. She was intubated and admitted to the Intensive Care Unit but her condition deteriorated further and, in the early hours of 12 April 2020, she was diagnosed with a cytokine storm.

“Despite all efforts to treat her, she suffered a cardiac arrest later that morning and her death was confirmed at 10.30 hours.”

The coroner added:

“Whilst Mary’s untimely death is first and foremost a tragedy for you her husband, for her children, and all her relations, colleagues and friends, it is for society too.

“As a society, it is important that we learn from all of the lives that have been lost as a result of this terrible pandemic and to consider the wider policy implications that may be lost from each and every one of these.

“Since this is a process which goes far beyond a coroner’s inquest and the Prime Minister has indicated his intention to hold a full public inquiry into the Covid-19 pandemic, I urge him to proceed with this as soon as practicable.”

Following the conclusion of the inquest into his wife’s death, Ernest Boateng said:

“The sudden death of my wife and the mother of our two children has been the hardest pain to bear. In those early days after Mary’s death, I was only able to carry on because of the need to care for our children and provide them with a loving home.

“Mary was strong, capable, vibrant, full of life and the most precious person in my life. It is still difficult to believe that she lost her life to the COVID-19 virus.

“I am glad that those who were involved in Mary’s care in the final weeks of her life have had to give a full account of what happened. I hope that the fact that they have had to do so will remind them of the need to always give the best possible care to women in Mary’s situation – especially black women who are themselves on the frontline of healthcare.”

Ernest’s solicitor, Leigh Day partner Suzanne White said:

“This has been a difficult week, for the family who have had to re live the traumatic events at the inquest leading up to Mary’s death from Covid 19.

“The inquest into Mary’s death has given a full and thorough account of what happened in the weeks leading up to her tragic death from COVID-19 and we thank the coroner for that.

“Ernest will take time to reflect on the accounts that have been given and will now consider his next steps. He now has to face the task of building a life for his two children who will have to face a future without their mother.”

Suzanne White
Birth injury Brain injury Cerebral palsy Inquests

Suzanne White

Suzanne White is head of the medical negligence team and has specialised in this area of law since qualifying in 1999.

Firdous Ibrahim
Amputation Birth injury Brain injury Cerebral palsy Spinal injury

Firdous Ibrahim

Firdous Ibrahim is a senior associate solicitor in the medical negligence department.

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