Inquest finds failures in care provided to a 56-year-old woman diagnosed with menorrhagia and uterine fibroids

The woman, whose family have asked for her to be known only as CN, was otherwise fit and healthy but had been suffering from very heavy periods, also known as menorrhagia.

After a hospital admission, during which it was found that CN was dangerously anaemic, she was diagnosed with uterine fibroids. In 2019 she was referred to the gynaecology clinic with a recommendation that she undergo a hysterectomy to treat the uterine fibroids. However, this gynaecology appointment never took place.

She was readmitted to hospital in June 2022 with further heavy bleeding caused by the fibroids. Shortly after being discharged home, she died from a pulmonary embolism which was caused by deep vein thrombosis (DVT).

An inquest was held to identify the cause of CN’s death. Her family were represented by Leigh Day solicitor Meg George and barrister Rajkiran Barhey of 1 Crown Office Row.

The Senior Coroner for East London, Graeme Irvine, recorded in his narrative conclusion that due to a breakdown of communication the recommended surgery was not undertaken and that had the surgery taken place, CN would probably not have developed a pulmonary embolism in June 2022. He also noted that CN’s DVT was made more likely by her uterine fibroids and her treatment for that condition, tranexamic acid.

The coroner also made a Prevention of Future Deaths Report, sent to the NHS Trust, NHS England and the Secretary of State for Health and Social Care, relating to two matters.

The first issue related to the failure to follow up on the recommendation for surgery. The coroner noted that “Although the trust has investigated these circumstances and implemented change, no clear explanation could be offered for why the deceased slipped out of this care pathway. I am not satisfied that the risk of re-occurrence has been properly addressed.”

The second issue related to the risk assessment at the hospital, which was used to identify whether patients were at risk of suffering from DVT. Of this he said “[t]he clinicians treating CN assessed her VTE risk utilising an established algorithm based on national guidance. The assessment was undertaken appropriately but it failed to identify two risk factors which made the formation of a DVT more likely, namely; large uterine fibroids and the use of tranexamic acid. I have concerns that the omission of these factors in the assessment criteria limited the effectiveness of the risk assessment.”

Meg George, solicitor from law firm Leigh Day who represented the family of CN, said:

“The importance of ensuring that patients are properly followed up cannot be emphasised enough. Had CN received the care that had been recommended she would probably not have developed a fatal pulmonary embolism.

“As uterine fibroids are a condition which only affect women and are more frequently observed in women from African and Asian backgrounds, failures to properly follow up patients with this condition disproportionately affect women of colour.

“I hope that the coroner’s findings and concerns help ensure that in future no other women, or their families, suffer such a tragic outcome.”