Coroner Issues Stark Warning After Hospital's Failure to Detect Brain Tumour
A coroner has issued a formal prevention of future deaths report to two NHS trusts after a 59-year-old woman took her own life just days after being discharged from hospital where doctors failed to discover a significant brain tumour.
Tragic Sequence of Events
Sarah Heaver, from Whitstable in Kent, was found unconscious at her home on May 21, 2024, with paramedics recording her Glasgow Coma Scale score at just three out of fifteen - the lowest possible measurement indicating severe neurological impairment.
She was admitted to the Queen Elizabeth The Queen Mother Hospital in Margate, where her condition initially improved, with her consciousness level increasing to eight on the same scale. Despite this concerning presentation with what medical staff described as "an unknown downtime and an unclear history," crucial neurological investigations were not undertaken.
A CT head scan was clinically indicated but never performed, and no structured neurological observations were conducted on a patient presenting with such profoundly low consciousness levels.
Missed Diagnosis with Fatal Consequences
Just six days after her hospital discharge, Sarah entered the sea at Whitstable with the intention of ending her life. Despite resuscitation attempts, she was pronounced dead in hospital.
A subsequent post-mortem examination revealed the shocking truth doctors had missed: Sarah had a large pituitary brain tumour that was putting significant pressure on her adrenal gland.
Coroner Sarah Clarke stated unequivocally in her report: "Although it is clear that Mrs Heaver entered the sea of her own volition with the intention to end her life, it is likely that an undiagnosed pituitary tumour putting pressure on her adrenal gland contributed to her declining emotional state."
Systemic Failures Identified
The inquest heard multiple concerning revelations about Sarah's care and the wider system failures:
- Sarah had been openly expressing suicidal thoughts to friends and family in the days and weeks before her death
- These concerns were properly flagged with hospital staff at QEQM
- She was seen by the hospital liaison psychiatry team and discharged under the care of the Crisis Team
- However, the coroner identified serious gaps in mental health support following discharge
Coroner Clarke expressed particular concern about: "patients discharged from acute hospital settings on the understanding that they will receive psychiatric input equivalent to hospital admission, only for it to later become apparent that there is no access to a psychiatrist or prescriber for several days, particularly over bank holiday periods."
Documentation Deficiencies
The investigation was further hampered by what the coroner described as "inconsistent, unreliable and incomplete medical records" that "significantly hindered my ability to investigate the death and created a risk of future patient harm."
Formal Responses Required
The prevention of future deaths report has been issued to both East Kent Hospitals University NHS Foundation Trust and Kent and Medway NHS and Social Care Partnership Trust, who now have 56 days to respond fully.
An EKHUFT spokesperson said: "We take the coroner's findings very seriously and will respond to her concerns in full. We offer our sincere condolences to Sarah's family and loved ones. We are committed to making any necessary improvements to patient safety and care."
A KMPT spokesperson added: "We are reviewing the report's findings and offer our sincere condolences to the family, friends and loved ones of Sarah Heaver."
The medical cause of death was formally recorded as immersion, with the pituitary adenoma and associated adrenal gland atrophy noted as significant contributing factors to her deteriorating condition.
