Muluembet Yohanes: Prevention of future deaths report

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The medical cause of death was   
1a. aspiration pneumonitis  
1b. ischaemic brain infarction  
1c. seizure 
1d. hyponatraemia  
2. Transsphenoidal surgery for removal of a giant pituitary adenoma on 24/01/2025  

How, when and where 
Muluembet Yohanes died on 25 February 2025 in ITU at North Middlesex  University Hospital from hypoxic brain injury following a likely seizure and cardiac arrest as a result of hyponatraemia, that in turn being a complication  transsphenoidal surgery. 

Conclusion 
Recognised complication of necessary surgery on a background of a naturally occurring disease process. 

When this did not resolve the following day, her son called 111. The outcome of  the call was for Mulu to speak to a clinician at a Clinical Assessment Service  within 2 hours. A pharmacist called Mulu back and advised home management.  During a second call to 111 on 1 February, advice was given that Mulu could  attend A&E. Later that morning Mulu suffered a seizure as a result of  hyponatraemia, a known complication following transsphenoidal pituitary  surgery. On arrival of paramedics she was in cardiac arrest. ROSC was achieved  and Mulu was taken to North Middlesex University Hospital where she was found to have a critically low sodium level and an irreversible hypoxic brain injury. She  was palliatively extubated and died in ITU on 25 February 2025. Post-operative  hyponatraemia after transsphenoidal surgery is a well recognised, potentially life threatening, complication, and severe hyponatraemia carries a high mortality,  even with treatment. It is not possible to say whether, had it been identified  earlier, Mulu’s death would have been avoidable. 

The MATTERS OF CONCERN are as follows:
Mulu underwent surgery to remove a giant pituitary tumour on 24 January 2025.  She was discharged home on 27 January with hydrocortisone for low cortisol  levels. She was given discharge / safety netting / red flag advice, both orally and in writing, which advised her to seek medical help immediately if she vomited more  than once. 

Following discharge, Mulu suffered intermittent vomiting. Her son called the NHS  111 service on 31 January at 16:00 hours. He reported that Mulu had undergone  brain surgery and had been vomiting for 48 hours. The outcome of the call was for Mulu to speak to a clinician in a local service within 2 hours. I heard evidence that neurosurgery is not a specified Pathways category, nor is it part of the “vomiting”  algorithm. The Call Handler on 31 January 2025 erroneously recorded Mulu’s  surgery as a “head injury” which resulted in it receiving a higher priority outcome  than it otherwise would have done.   

An ANP called Mulu back at 16:57. They took an account that Mulu had  undergone surgery to remove a pituitary tumour a week previously and that she  had been vomiting since the previous day, that she vomited when she ate food  but that she was drinking well. The disposition reached was “home  management”, this being that she was to ensure that she remained well hydrated and to eat in small amounts. They advised that if she was unable to keep fluids  down and had symptoms of dehydration, she would need to be seen in A&E.  Again, there was no prompt in relation to brain surgery or for questions about any discharge advice.  

At 09:37 on 1 February, Mulu’s son again called 111 reporting that she had  deteriorated. As he was not with Mulu, no assessment was conducted but advice was given repeatedly that Mulu could attend hospital or contact 111 directly if she remained unwell.  

At 11:21 on 1 February 2025 Mulu was found unresponsive and an ambulance was called. Paramedics arrived at 11:40 and found Mulu in cardiac arrest. It is likely that Mulu suffered a seizure, followed by cardiac arrest, due to 
hyponatraemia.  

Neither the 111 nor Clinical Assessment Service asked Mulu whether the hospital had given her any post-surgical discharge, worsening or red flag worsening advice. Had they done so, this may have prompted Mulu to review the written  discharge advice she had been given. That advice was that vomiting was a safety  alert; that repeated vomiting required immediate medical help; that any  concerning symptoms required medical attention from a GP, A&E or UCLH  directly and that for persistent vomiting, advice on hydrocortisone should be  sought from 111, 999 or A&E.
 
1.  LAS informed me that they have advised Pathways of Mulu’s case and  recommended that Neurosurgery be added to the supporting information 
for “head injury” and “vomiting” algorithms. I do not know if Pathways  have, or have agreed to, action this or what the timescales are.   
2.  I am concerned that without a dedicated pathway for “neurosurgery”, it is  left to call handlers to choose the most appropriate pathway. To me, “head
injury” is not reflective of elective, non-trauma surgery.   
3.  Pathways does not include a question for post-discharge surgery patients 
about whether they have been given discharge, worsening or red flag  advice by their surgical team.   

I also may send a copy of the report to any other person who I believe may find it useful or of interest. 

I can confirm I have sent the report to: 
1. Mulu’s family
2. University College London Hospitals NHS FT 
3. Royal Free London NHS FT 
4. London Ambulance Service NHS FT 
5. London Central & West Unscheduled Care Collaborative
 
I also have a duty to send a copy of the report to the Chief Coroner.
 
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