Trevor, Inquest into the Death of [2023] NICoroner 3 (19 April 2023)

Parties

Procedural Posture

Inquest / Findings Delivered After Full Inquest With Oral and Written Evidence

Legal Issues

1. 1 Whether there were missed opportunities in the care and treatment of Gillian Trevor leading to her death
2. 2 Whether the medical management at Causeway Hospital was adequate and appropriate
3. 3 Whether the cause of death was properly established and attributable to substandard care

Ratio Decidendi

The death of Gillian Trevor was caused by cerebral infarction due to subdural empyema resulting from sinusitis. There were multiple missed opportunities for earlier diagnosis and intervention during her hospital attendances, including failure to seek urgent ENT input, failure to perform timely MRI or contrast CT imaging, and inadequate documentation and consultant review. These failures, on the balance of probabilities, contributed to her death.

Court Disposition

Death by misadventure contributed to by missed opportunities and inadequate medical management

Orders

• No formal orders as this is an inquest, but recommendations for improved clinical practice, documentation, senior review of re-attendances, and awareness of cerebral empyema as a complication of sinusitis.