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Nurse's care a case of 'what not to do', coroner says

Fieldfisher/family handout The three woman are standing in a home, smiling at the camera. Lisa has her arm around Chloe, who is wearing a pink top and cardigan. Lisa and Jeannette are in a black top and both wearing a necklace. Fieldfisher/family handout
Chloe, with her aunt Lisa and grandmother Jeannette Every, in Australia in 2018

The care of a 27-year-old woman who died after hospital treatment was "an example of what not to do” a coroner has said.

Chloe Every had learning difficulties and a muscle-wasting condition and was admitted to Queen’s Hospital in Romford in April 2019 where a scan revealed possible signs of cancer.

Coroner Graeme Irvine spoke about the consent necessary for procedures to be carried out, after Ms Every was given an enema while appearing to be asleep.

Mr Irvine, sitting at East London Coroner’s Court, praised Ms Every’s family for their “grit and tenacity” to uncover the failures in her care, saying that without their determination “an investigation would not have taken place at all”.

Fieldfisher/family handout Chloe with her aunt Lisa and grandmother Jeannette. She is wearing a top that says 'Mama' on it. Fieldfisher/family handout
Chloe, centre, had myotonic dystrophy and struggled to communicate

Barking, Havering and Redbridge University Hospitals NHS Trust referred the case to the coroner in 2019, advising that the cause of death was advanced cancer and myotonic dystrophy (MD), but further investigations took place suggesting there were potential areas of concern.

A post-mortem examination was not held.

Ms Every's aunt, Lisa Every, had previously told the inquest her niece was “still sleeping” when she was given an enema on 8 May 2019.

Nurse Asia Bawah, who carried out the procedure, told the court that she felt Ms Every had “consented non-verbally”.

She said Ms Every had been asleep when she went into her room and did not respond to her verbally when she explained she needed to administer an enema.

She told the court Ms Every did not open her eyes but turned to her left side after she asked her to.

Ms Bawah said she believed she had informed consent.

Ms Every was found unresponsive and resuscitation took place after being cleaned a few minutes later.

She was later moved into a general ward, where she died on 14 May 2019.

Every family Chloe Every pictured holding a champagne flute with a sparkling liquid inside. She appears to be in a restaurant or similar environment, with tables and flowers. She is wearing a navy and white striped top and is looking toward the camera as if making a toast.Every family
An initial cause of Chloe's death was found to be natural

Lisa Every previously told the court: “I asked Asia if it was OK to give Chloe the enema whilst she was still sleeping. I cannot recall a response. She proceeded.”

The coroner said: “The evidence I have heard from nurse Bawah did not demonstrate an appropriate consent process.

“In terms of the training need we have identified in this inquest, I make it abundantly clear this was an unacceptable set of circumstances and features."

At the end of her evidence, the coroner told Ms Bawah: “I am critical of your practice, of your care of Chloe.”

He said he had “concerns” about her standards of performance regarding basic life support, record-keeping and her “probity”.

He told Ms Bawah she should refer herself to the nursing regulator.

In summing up on Friday, the coroner said the lapses in note-taking were so bad that they were potentially “dishonest”.

The inquest continues.

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