Sultana Choudhury

I am Graeme Irvine, senior coroner, for the coroner area of East London

On 19th December 2022 this Court commenced an investigation into the death of Sultana Razia Choudhury aged 60 years. The investigation concluded at the end of the inquest on 24th August 2023. The court returned a short form conclusion of accident contributed to by neglect. Mrs Choudhury’s medical cause of death was determined as; Multi-organ Failure HypovolaemiaRenal Haemorrhage secondary to Renal Biopsy (7th December 2022)

Sultana Choudhury was diagnosed with Diabetes and chronic kidney disease, she agreed to take part in a research project related to these conditions. On 7th December 2022 she consented to undergo a renal biopsy to harvest sample material in furtherance of the research programme. The procedure was completed after two attempts to take tissue. A week later Mrs Choudhury was admitted into hospital with abdominal pain, haematuria, rapidly worsening acute kidney injury and a positive for gram negative rods in blood cultures. Following diagnostic testing and imaging, Mrs Choudhury was admitted for treatment of a queried diagnosis of pyelonephritis and was administered enoxaparin for VTE risk. Mrs Choudhury was not adequately monitored whilst an inpatient. She died following a cardiac arrest in hospital on 17th December 2022. The cardiac arrest was caused by hypovolaemia which, in turn was caused by a undiagnosed renal haemorrhage the result of the renal biopsy 7 days earlier. The haemorrhage was exacerbated by contraindicated VTE prophylaxis.

During the course of the inquest the evidence 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. –

1. The trust’s failure to diagnose an obvious ongoing renal haemorrhage in a patient with; a recent history of renal biopsy, worsening clinical observations in keeping with hypovolaemia and a plummeting haemoglobin count.
2. The clinical decision to administer VTE prophylaxis in the form of low molecular weight heparin on admission to a patient with a patent bleed, evidenced by haematuria.
3. The failure to adequately monitor Mrs Choudhury during her 3-day admission that allowed her to deteriorate into a preventable peri-arrest state.

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.