Published: 15 June, 2012
by WILLIAM McLENNAN
A 49-YEAR-OLD council worker who died from a blood infection had shown no signs of the illness days before her death when she was examined by specialist doctors who were “working to some extent in a bubble”, an inquest heard this week.
Agatha Nwosu, 49, who worked for Islington Council, died of multiple organ failure after an artificial tube, inserted in her bile duct to clear a blockage, became infected.
Ms Nwosu, who lived in Woodberry Down, Hackney, visited three hospitals in Camden and Islington for treatment of jaundice and a rare type of tumour in her pancreas. She was passed between specialists at Whittington, Royal Free and University College hospitals.
Assistant coroner Shirley Radcliffe told a St Pancras inquest on Tuesday: “It’s a problem of three different hospitals and lots of doctors and not one person there had a clear idea of what was happening.”
Dr Radcliffe said referring Ms Nwosu from one doctor to another led to the situation where each one “hasn’t quite got the full picture”.
Three days before she was taken into intensive care, Ms Nwosu was examined by a tumour specialist at the Royal Free Hospital, in Hampstead, who did not detect any signs of the infection.
Fears of sepsis – when infection passes into the bloodstream – were first raised by Dr Pauline Leonard, an oncology consultant at Whittington Hospital, in Archway, when Ms Nwosu reported feeling cold shivers on December 9.
Despite the shivers, Dr Leonard said Ms Nwosu seemed surprisingly well and prescribed her antibiotics.
The infection was thought to be caused by a blockage in the artificial tube, called a stent, in Ms Nwosu’s bile duct.
Concerns were raised that the stent had become blocked when her jaundice failed to subside, the court heard.
No steps were taken to investigate the possible blockage when Ms Nwosu visited the Whittington on December 6 to see a gastroenteritis specialist, because a meeting of specialists at the Royal Free was scheduled to discuss Ms Nwosu’s treatment the following week.
Dr Radcliffe said: “We cannot be sure that an earlier change of stent would have prevented sepsis, but on the balance of probabilities the outcome may have been better.”
The inquest heard that Ms Nwosu was not contacted for 11 days between December 9 and December 20.
Dr Radcliffe said: “You can understand that there must be quite a lot of family concern that there had not been any contact. It was naturally a very worrying time. They were in limbo.”
Ms Nwosu sent an email to Dr Leonard on December 16, outlining the rapid deterioration in her health, but sent it to the wrong address and it was not received until after her death.
Speaking about the undelivered email, Dr Leonard said: “I would have been very worried and would have instructed her to come to the emergency department.”
Dr Leonard phoned Ms Nwosu on December 20 when she described feeling “terribly upset that things were taking so long”. Ms Nwosu was referred to a department at the Royal Free that specialises in treating the rare tumour and was examined on December 23.
On December 26 she was taken to intensive care at the Royal Free. Two days later Ms Nwosu was sedated and she died on January 5.
Dr Radcliffe recorded a narrative verdict. “We have had very clear evidence that, with all the best will in the world, having so many specialists has led to a certain element of fragmentation, not having the same doctor there following throughout, having a single point of contact,” she added.