Jennifer Trigger

I am John Adrian Gittins, Senior Coroner for North Wales (East and Central)

On the 28th of September 2020 I commenced an investigation into the death of Jennifer Ann Trigger (DOB 27.12.48 DOD 31.1.20). The investigation concluded at the end of the inquest on the 29th of February 2024. The cause of death was recorded as being due to 1(a) Extensive intra-cranial bleed 2. Warfarin Therapy and the conclusion of the inquest was that of natural causes contributed by neglect.

On the evening of the 29th of January 2020, the deceased was admitted to the Wrexham Maelor Hospital after becoming unwell. It was established that she had suffered an acute stroke and as she was on warfarin for a pre-existing condition, she was appropriately prescribed beriplex by way of treatment to reduce the risk of an extension of the bleed in her brain. Although this was prescribed at around 20.45 it was not administered until 07.35 the following morning despite it being a time critical treatment. By this time there had been an extension of the bleed with associated oedema and her condition had deteriorated significantly. Despite medical intervention and treatment in intensive care she was verified deceased at 18.30 on the 31st of January 2020

During the course of the inquest the evidence revealed the following matter giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTER OF CONCERN is as follows. There was a miscommunication or misunderstanding when a ward nurse bleeped a junior doctor with a view to action being taken in relation to the administration of the beriplex infusion. This resulted in a delay in the doctor attending as she did not prioritise a task which was time critical and the subsequent delays resulted in an unrecoverable deterioration in the patient’s condition. Evidence was received in the course of the inquest that the current bleep system did not enable information to be conveyed electronically and that this in turn created a risk of misunderstanding as to work requirements and hence impacted upon prioritisation of tasks and therefore potential delays, the effects of which (as in this case) could be catastrophic in terms of patient safety. Evidence was also given that alternative systems existed that had the potential for mitigating or eliminating such risk by way of the electronic transfer of information and requests to doctors.

In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action.