AN investigation is to be held into the death of an Old Colwyn woman who died just 24 hours after being admitted to hospital in May, 2012.
An inquest in Ruthin heard that a lumbar puncture carried out on Lorraine Pitt at Glan Clwyd Hospital exacerbated pressure on her brain after she had been suffering from severe headaches for about two years.
John Gittins, the coroner for North Wales East and Central, recorded a conclusion of accidental death on the 46-year-old health and safety manager because, he said, the lumbar puncture was a “key component” in her death even though he actual cause of death was natural.
But he said that he did not intend at this stage to submit a report under Regulation 38 of Coroner’s Rules which aim to prevent future deaths because he would await the outcome of a serious incident review being carried out by the Betsi Cadwaladr University Health Board.
”I am reserving judgment on whether a report is required and if I feel that the review has highlighted areas where action should be taken I shall do that,” he said.
Mr Gittins said he would ensure that Mrs Pitt’s husband, Dr Christopher Pitt, was kept informed of the review and any further action.
Dr Pitt, of Alpine Road, Old Colwyn, said he and his wife, whom he described as “a very kind, friendly person who seemed to have an aura of calm”, moved to North Wales from London in 2011 after she was made redundant.
She had suffered from migraine for many years but the headaches became much worse, lasting for hours. By 2012 she was also stumbling quite often and her vision was affected.
When her condition deteriorated rapidly within a week her GP Dr Suriakant Patel had her admitted to hospital in March, 2012, but she was discharged because nothing wrong could be found.
Dr Pitt, who was still working in London, said his wife developed shingles and felt that so many things were going wrong that no-one would believe her.
The headaches were so bad that she would thrash around in bed.
He took his wife to hospital, where she seemed to be “staring through him” and her eyes rolled back in her head, as if she was fitting.
Dr Gerallt Owen, the general physician on call that night, said a scan had failed to reveal anything and so he decided to carry out a lumbar puncture, a procedure to investigate conditions in the brain.
Asked by the coroner “The timing of her death must have had an association with that procedure, mustn’t it?” Dr Owen replied “Yes”.
Mr Gittins said he was aware that the case had weighed very heavily with him, but asked: “With that in mind do you feel that anything has changed in your practice?”
Dr Owen replied: “I think I spend more time with families discussing diagnostic levers.”
A post-mortem examination revealed that Mrs Pitt died of tonsillar herniation, an increasing of pressure on the brain.