Koforowola Alwajud Died Following Brain Injury Caused By Blood Clot After Cardiac Arrest Diagnosis Was “Held Up And Hampered” By Staff

The husband of a mum-of-four who died after resuscitation following her cardiac arrest diagnosis was “held up and hampered” by staff at a London mental health unit, is calling for urgent improvements to patient safety following the inquest into her death.

Koforowola Alwajud – known as Kofo - died aged 45 in Charing Cross Hospital on January 9, 2016 days after the heart attack she suffered at Hammersmith and Fulham Mental Health Unit left her with irreversible brain damage.

Kofo’s husband Rotimi Oluwagbemiga, from Bromley, instructed specialist medical negligence lawyers at Irwin Mitchell to investigate the care his wife received after her death. A serious incident report subsequently raised a range of concerns regarding the quality of care following her cardiac arrest, including criticisms related to taking observations, note-keeping and the management of resuscitation.

The eight-day inquest into her death, held before a jury of 10 at the West London Coroner’s Court heard that on January 1, 2016 Kofo was discovered some time after 2pm lying on her bed. She was reported as breathing lightly, but a pulse could not be found.

It transpired that she had suffered a cardiac arrest but this was not immediately recognised.

Delivering their conclusions on Thursday March 30, 2017, the jury of 10 said “the process of addressing Mrs Alwajud’s condition from this point was held up and hampered by a number of factors.”

The failings included:

• Inability of staff immediately attending her to recognise her condition, and undertake the necessary life support procedures
• A delay in summoning assistance owing to failure of a personal alarm and the duty doctor’s mobile and office numbers receiving no response when dialled
• An inability to brief the duty doctor of the emergency nature of the situation, with subsequent unpreparedness for the condition of the patient
• The CPR subsequently initiated by the doctor being compromised by inability to move the patient to an optimal position for treatment
• Two interruptions to the treatment due to the doctor being alone in the room and having to summon assistance.

They added that there was an inability to deliver high quality oxygen to Kofo because of inadequate support in assembling the bag valve mask and operating the oxygen cylinder.

Delivering a narrative conclusion, the jury said: “From the evidence received we believe there were failings at every stage of her stay in Avonmore Ward, but that the decisive factor leading to her death was the delay in cardiac arrest being recognised and effective life support measures being undertaken.”

The jury then listed eight separate factors which they said “compromised the outcome of Mrs Alwajud’s care”, including:

• Lack of physical/medical assessment
• Delay in initiating and subsequent incomplete medical testing
• Incomplete and inconsistent record keeping and lack of oversight of record keeping
• Lack of follow through of care plans, hence inability to identify trends and inter-related conditions.
• The lower priority given to physical health issues in a mental health setting.”

Mr Oluwagbemiga said he is keen to ensure that lessons are learnt to prevent other families from going through the same ordeal his wife suffered, and he is still coming to terms with today.

Expert Opinion

“Kofo was a vulnerable woman and her loved ones placed great faith and trust in Hammersmith and Fulham Mental Health Unit to care for her.

“The details heard at the inquest are hugely concerning and it is vital that the Hammersmith and Fulham Mental Health Unit show that lessons have been learnt from this tragic case. The safety of patients should always be the fundamental priority.”
Anna Vroobel - Senior Associate Solicitor

Mrs Alwajud was initially admitted to the Avonmore Ward of Hammersmith and Fulham Mental Health Unit under the Mental Health Act on December 24, 2015 following concerns regarding recent behaviour.

She refused to eat or drink on numerous occasions following her admission and  spent significant amounts of time lying in bed, not engaging with staff attempts to speak to her. On January 1, 2016 Mrs Alwajud was found lying on her bed unresponsive.

She was then transferred to Charing Cross Hospital where she was intubated and ventilated, but brain tests on January 5 confirmed she had suffered irreversible damage as a result of the cardiac arrest. She sadly passed away on January 9.

Following the hearing Mrs Alwajud’s husband Mr Oluwagbemiga said: “The information we have heard regarding Kofo’s death is deeply distressing and we hope that steps have been taken to ensure no one else faces the problems that she did.

“The entire family remains devastated by her death, particularly our four young children who have been left without their mother. I only hope that if anything positive comes from this, it is an improvement in the quality of care that mental health patients receive.”

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