Coroner rules 22-year-old Beatrice Lovane died due to fatty liver and paracetamol-induced liver damage
Date published: 11 August 2017
A coroner has ruled that 22-year-old Beatrice Lovane died due to ‘combined effects’ of a fatty liver and acute liver damage as a result of paracetamol toxicity.
Ms Lovane, from Falinge, Rochdale, died on 27 August 2016 at Fairfield General Hospital after suffering from breathing problems at home. An inquest into her death opened on 24 March.
Coroner Hashmi concluded at the Coroner's Court in Heywood: “Ms Lovane died as a result of the combined effects of natural causes (namely, impaired liver function consequent upon fatty liver disease) and acute liver damage (necrosis) due to paracetamol toxicity. It was not possible, on the evidence heard, to identify the exact point at which the acute liver damage arose.
“Whilst the evidence demonstrated, to the required legal standard, that there had been gross failures to provide basic medical care to the deceased who, by virtue of the circumstances, was in a dependent position it was not possible to causally link the gross failure/s in care to the cause of death.
“The standard of care provided by the Ambulance Service on this occasion was outwith expectation.”
At 9:39pm on the 26 August 2016, an emergency ambulance was called to attend Ms Lovane at her home address in Falinge, Rochdale, as she was suffering from breathing problems.
A rapid response paramedic arrived at 9:53pm and diagnosed her with hyperventilation. On balance, this was incorrect.
During the course of the paramedic's attendance, Ms Lovane declined intervention on several occasions and refused admission to hospital.
Whilst at home, Ms Lovane suffered a number of collapses. The collapses were, more likely than not, a subtle sign that her condition was deteriorating.
Additional paramedic support was requested, arriving at around 11:02pm.
After a protracted period of negotiation Ms Lovane was finally coaxed downstairs, supported by her mother rather than the paramedics.
Police assistance was requested at around 00:07am by the attending paramedics.
The inquest hearing heard ‘there was no good reason to call for police attendance’ as there had been ‘no escalation to the Ambulance Service Hub for advice or further assistance at any point’.
As Ms Lovane reached the bottom of the last of four flights of communal stairs, she collapsed. Timely steps were not taken to instigate emergency treatment and basic life support. There were delays in identifying the cause of her sudden collapse. Her vital signs deteriorated rapidly and it was clear from her presentation that she was rapidly losing consciousness.
After approximately ten minutes, with little if any intervention, Ms Lovane was placed on a stretcher and taken to the ambulance whereupon she immediately went into cardio-respiratory arrest.
Cardiorespiratory resuscitation (CPR) was commenced and Ms Lovane was conveyed to Accident & Emergency department where she subsequently died at 2:31am on the 27 August 2016, despite the best efforts of the hospital staff to save her.
The Ambulance Trust, through its Root Cause Analysis (RCA), identified a number of significant errors and omissions on the part of the attending crew.
The RCA was reviewed in light of additional information and further steps have now taken to address all the issues identified.
Whilst the evidence demonstrated, to the required legal standard, that there had been gross failures to provide basic medical care to the deceased who, by virtue of the circumstances, was in a dependent position, it was not possible to causally link the failure/s in medical care the cause of death.