Europe-wide alert after inquest told Ellesmere woman died from swelling of brain
Medics throughout Europe have been alerted to the circumstances which led to the death of an Ellesmere woman in Hospital.
Kate Jones, 34, from Ellesmere, died at the Maelor Hospital in Wrexham in March 2017.
At an inquest in Ruthin on Wednesday the coroner was told that new European safety guidelines had been issued following her death.
The mother-of-three, of Swan Mere Close, died from swelling of the brain 10 days after being admitted to hospital.
She had been admitted and diagnosed with having gastro-enteritis and given appropriate medication, which cured the problem, but she continued to have high blood pressure, something from which she had suffered for many years.
Miss Jones received medication for the hypertension and was being considered for discharge but her family became concerned when her behaviour change and she later became unresponsive.
Hospital staff told the inquest of ongoing concern about low sodium and potassium levels in her blood, for which she was medicated.
When a scan was eventually carried out the brain swelling was revealed.
Dr Stuart Robertson, consultant nephrologist, who headed the internal investigation after her death, said thoughts that Ms Jones may be suffering from alcohol withdrawal, which could have caused confusion and behavioural changes, was a “red herring” and the treatment for the blood pressure and low sodium and potassium had been appropriate.
It was unfortunate, however, that the link between the change in behaviour and the brain swelling was not made sooner.
“Early intervention may have changed the outcome but it was a very complex situation,” he said.
The swelling would have been caused by the sudden and marked decrease in sodium level.
Dr Robertson said that in his 25 years’ experience he had never come across such consequences of a rapid drop and he said that correcting sodium levels too quickly, he added, could actually cause brain damage.
He told the inquest that local guidelines were about to be issued following Miss Jones’ death when European guidelines were received.
Another step taken as part of an action plan is that when critically low sodium levels are found staff on the particular wards are notified that it could be life-threatening.
Recording a narrative conclusion, David Pojur, assistant coroner for North Wales East and Central, said that after learning what steps had already been taken he did not see the need to issue a Regulation 28 report to prevent future deaths.
Following the inquest Miss Jones' family declined to comment.
