Evans, Re an inquest into the death of [2019] NICoroner 3 (12 April 2019)

Evans, Re an inquest into the death of [2019] NICoroner 3 (12 April 2019)

The failure to have the deceased assessed by a doctor at 5pm on 14th October 2015 constituted a loss of opportunity in her care. On the balance of probabilities, had proper treatment commenced at that time, the outcome would have been different, despite the rarity of epiglottitis.

Citation
[2019] NICoroner 3
Parties
Deceased: Melanie Catherine Evans; Coroner: Coroner Patrick McGurgan
Jurisdiction
Northern Ireland
Judgment Date
12 April 2019
Procedural Posture
Inquest / Final Judgment
Outcome
Findings of loss of opportunity and recommendations for improved training and guidelines; no criminal or civil liability assigned.
Legal Topics
Inquest Into Death, Medical Negligence, Hospital Procedures, Epiglottitis, Loss of Opportunity
Coronial Law Medical Law Inquest Into Death Medical Negligence Hospital Procedures Epiglottitis Loss of Opportunity

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Parties

Melanie Catherine Evans

Deceased

Coroner Patrick McGurgan

Coroner

Procedural Posture

Inquest / Final Judgment

Legal Issues

  1. 1 Whether the care and treatment provided to Melanie Catherine Evans was appropriate and timely
  2. 2 Whether failure to assess the deceased at 5pm on 14th October 2015 represented a loss of opportunity affecting the outcome

Ratio Decidendi

The failure to have the deceased assessed by a doctor at 5pm on 14th October 2015 constituted a loss of opportunity in her care. On the balance of probabilities, had proper treatment commenced at that time, the outcome would have been different, despite the rarity of epiglottitis.

Court Disposition

Findings of loss of opportunity and recommendations for improved training and guidelines; no criminal or civil liability assigned.

Orders

  • Recommendation for increased training on epiglottitis for ED and general medical staff.
  • Recommendation for ongoing review and refinement of hospital guidelines regarding sore throat and airway management.