Jade Revell

I am SARAH HUNTBACH ASSISTANT CORONER for the coroner area of Derby & Derbyshire

On 05 January 2022 I commenced an investigation into the death of Jade Paula REVELL aged 30. The investigation concluded at the end of the inquest on 22 March 2023. The conclusion of the inquest was that: Jade Revell was taken to Chesterfield Royal Hospital on 25 December 2021 having suffered a sudden cardiac event at home. Despite extensive resuscitation she passed away in hospital the same day. Jade suffered with an eating disorder and was under the care of the mental health team. Prior to making a change to her medication her bloods were tested. On 27 October 2021 the bloods were electronically sent to Jade’s GP practice. These showed a low potassium level which required further action. There was a failure to notify Jade of this result. This caused a missed opportunity to medically treat the hypokalaemia and monitor the potassium levels which increased the risk of ventricular fibrillation and sudden cardiac death.

Jade Revell died from a sudden cardiac event. A missed opportunity to treat hypokalaemia shown in blood results on 27 October 2021 has more than minimally contributed to the cause of the sudden cardiac event.

During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: (brief summary of matters of concern) The SystemOne computer programme used by the GP Practice can, when a clinician is reviewing the results (blood) from the laboratory with the screen in minimised mode (which is not unusual because of a need to work with a split screen), not show all the results.  To do so would need the clinician to scroll down and a scroll feature is not available.  This gives rise to the risk of an abnormal result being missed and unactioned. Abnormal (out of range) should be more visable – appear at the top of a list and colour coded to minimise the risk of a result not being seen / missed. The computer programme prevents this.

In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action.