Colchester woman's death 'could have been avoided' coroner rules

A four-day inquest finished on Wednesday as area coroner for Essex Sonia Hayes recorded a narrative conclusion into the death of Chloe Hunt.

Mrs Hayes ruled she could have been saved had pens been removed from her stomach sooner by surgeons.

The inquest heard how Miss Hunt self-harmed by swallowing the pens on March 11, 2022.

An operation to remove them did not take place for another three days, and Miss Hunt died of cardiac arrhythmia hours after two of the four pens were extracted.

Conclusion - an inquest into the death of Chloe Hunt concluded on Wednesday (Image: Newsquest)

The inquest heard Miss Hunt told mental health nurse Paul Tappin about the self-harm “as if she was talking about the weather”.

Mr Tappin then phoned 999, but “did not wait to see whether Chloe was going to be safe” even though it was an emergency situation.

Mrs Hayes described the approach as “somewhat surprising”.

After Miss Hunt was admitted to Colchester Hospital, a CT scan identified the four pens lodged in her duodenum, but use of general anaesthetic to remove the pens was not considered.

Miss Hunt found it difficult to stay in the hospital due to her mental disorder and discharged herself before returning two hours later.

An operation did not take place until March 14, and it was considered “unusual for the pens to be left in situ for so long”.

During her time in hospital, Miss Hunt had a high heart rate and low blood pressure, with clinicians showing “a lack of curiosity” as to why that was, the coroner said.

Miss Hunt suffered a cardiac arrest shortly before 6am on March 15, but the inquest heard there was a problem connecting the defibrillator pads to the machine during resuscitation.

Delay - the inquest heard there were problems connecting defibrillator pads to the machine (Image: Newsquest)

Mrs Hayes said: “I have considered the resuscitation and the time it has taken for the crash team to get the first readings during the resuscitation.

“It was nearly 20 minutes before the first blood reading was given - this is unacceptable.”

Mrs Hayes provided a cause of death of fatal cardiac arrythmia secondary to metabolic derangement due to gastrointestinal obstruction caused by pens in the stomach and duodenum.

She said: “The delay to an operation could have been avoided.

“I am satisfied she was awaiting surgery on the day she died - tragically, this proved too late for Chloe.”

Dr Angela Tillett, the chief medical officer at East Suffolk and North Essex NHS Foundation Trust, said the hospital has already made 'significant changes' in light of Miss Hunt's death.

She said: "We would like to extend our deepest sympathies to Chloe’s family.

"We have already made significant changes in the light of this tragic event and will take all the findings from the coroner to ensure further learning across the trust."