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Coroner raises concerns after reaching open conclusion into hospital death

PUBLISHED: 16:28 08 May 2018 | UPDATED: 18:48 08 May 2018

Kirsty Tolley, 28, died at the Queen Elizabeth Hospital in King's Lynn on February 19, 2017. Picture: Sue Tolley

Kirsty Tolley, 28, died at the Queen Elizabeth Hospital in King's Lynn on February 19, 2017. Picture: Sue Tolley

Sue Tolley

All a mother wanted was answers but an inquest into her daughter’s death reached an open conclusion.

Kirsty Tolley pictured on her last Christmas before she passed away in February 2017. Picture: Sue TolleyKirsty Tolley pictured on her last Christmas before she passed away in February 2017. Picture: Sue Tolley

Kirsty Tolley, 28, died at the Queen Elizabeth Hospital (QEH), in King’s Lynn, on February 19, 2017, nine days after she was admitted.

An inquest into her death heard she had gone to hospital with bruising and pain in her leg and a high temperature.

A year before, in June 2016, Kirsty went to the QEH with similar symptoms and was found to have acute anaemia and underwent emergency surgery to relieve pressure in her leg. During that time she had been given three units of blood.

On admission to hospital in February 2017, her blood count showed her haemoglobin level was 77g per litre and so an initial plan was put in place for daily blood tests to be carried out.

Kirsty Tolley had a passion for snakes, pictured here on her 28th birthday, the last birthday she would celebrate before she passed away in February 2017, Picture: Sue TolleyKirsty Tolley had a passion for snakes, pictured here on her 28th birthday, the last birthday she would celebrate before she passed away in February 2017, Picture: Sue Tolley

On February 16, 2017, Kirsty was given an iron infusion called Ferrinject to boost her iron levels and only one subsequent blood test was carried out - at the time of her death, which showed her haemoglobin levels had risen.

But in her summary, senior coroner Jacqueline Lake said the test result could not be relied upon as earlier evidence heard from Dr Martin Goddard, from the Royal Papworth Hospital, states that an increase in blood within three days was out of proportion. Kirsty’s last blood test was carried out on February 16, which showed her haemoglobin level dropped to 61g.

Haematologist Dr Lisa Cook decided a blood transfusion could only be given to Kirsty if she had shown symptoms such as low blood pressure, fast heart rate or shortness of breath, but consultant Dr Hiddadin said she had shown no symptoms each time he saw her.

As the cause of death was recorded as unascertained, Ms Lake gave an open verdict at the conclusion of the inquest.

A young Kirsty Tolley. Picture: Sue TolleyA young Kirsty Tolley. Picture: Sue Tolley

Ms Lake said she was concerned that regular blood tests were not carried out by the staff and observation checks were not carried out regularly for staff to note her early warning score, which determines the degree of illness of a patient.

Ms Lake said she will produce a report after speaking with staff at the hospital to prevent future deaths.

She added that once a patient reaches an EWS of level three a patient should be checked more regularly which did not happen in Kirsty’s case and notes of observations were not made. 
“It may have thrown some light into the medical cause of death, I don’t know,” Ms Lake added.

“Unfortunately the family are left in that position, they don’t have the answers that could’ve been available, but I don’t know.”

Kirsty Tolley with her sisters Tine, Stephanie and Terrie. Picture: Sue TolleyKirsty Tolley with her sisters Tine, Stephanie and Terrie. Picture: Sue Tolley

‘She was our world’

Kirsty Tolley’s mother, Sue Tolley, said her daughter had been in hospital in 2016 with similar symptoms and had three units of blood when doctors operated on her left leg to ease the swelling.

Mrs Tolley said: “I told the consultant don’t let her die on me, it has always been a worry of mine every time she went into hospital.”

On February 10, 2017, when Kirsty was admitted again to the QEH with similar symptoms of a swelling in her right leg and a low blood count, Mrs Tolley believed she needed a blood transfusion as she was showing symptoms of her severe anaemia.

A young Kirsty Tolley with her mother Sue Tolley. Picture: Sue TolleyA young Kirsty Tolley with her mother Sue Tolley. Picture: Sue Tolley

Instead she was given an iron infusion called Ferrinject as doctors specified that she was only to be given a blood transfusion if she was showing symptoms. 
But on February 19, Mrs Tolley received a call from Kirsty’s carer saying she had gone into cardiac arrest and was being resuscitated. 
“We got there pretty fast,” Mrs Tolley said. “They were still working on her and I told them don’t you let her go.”

But after 55 minutes of trying to resuscitate her, Kirsty Tolley died in hospital in the Tilney Ward, aged 28.

Mrs Tolley said her daughter had complex needs from birth but that it did not deter her from wanting to live a fulfilled life.

“When she was younger you wouldn’t know she was special needs,” said Mrs Tolley. “But over the years she went downhill.”

Kirsty had severe learning difficulties, epilepsy, autism and anaemia and required 24 hour care.

At the time of her death, Kirsty was living in a bungalow in Walsoken and had carers help her with day-to-day tasks.

“She wanted to do what her sisters were doing, to leave home and live on her own and make her own decisions,” Mrs Tolley added.

Kirsty enjoyed visiting charity shops and putting together jigsaw puzzles. She could even tackle a 3,000 piece jigsaw in no time at all, her mother said.

And although the sight of snakes may make most people run with fear, Kirsty enjoyed their company and the reptiles made a surprise visit to her home on her 28th birthday, the last birthday she celebrated before passing away.

“Snakes - she had a passion for them,” Mrs Tolley said. “It was the feel of them, they had a calming effect on her.”

Kirsty leaves behind three sisters - Tina Adams, 35, Terrie Watson, 32, and Stephanie Johnson, 34 - her father Cameron Tolley and 10 nieces and nephews.

Mrs Tolley said: “She loved spending time with them, she couldn’t wait for her nieces and nephews to grow up.
“I try to think she hasn’t gone and that she isn’t talking to me, she had bouts of not speaking to me but then she’d forget about it.

“She was a funny little girl, she was our world.”


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