TRAGIC LOSS
‘Beautiful’ mum-of-two, 35, died of ‘silent killer’ after suffering cold, clammy hands and shortness of breath
Kayleigh “would likely have survived” had she been diagnosed correctly and treated properly, the coroner says
A MUM-of-two died of a blood clot after suffering cold, clammy hands which medics mistook for another, less serious condition.
Kayleigh Colegate, from Rhyl in Wales, visited her GP surgery on May 16, 2022 after experiencing shortness of breath so severe she could barely walk between rooms.
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A nurse noticed the 35-year-old childcare leader's hands were cold and clammy, according to .
Kayleigh could only speak in short sentences, raising the nurse's suspicion of a possible blood clot in her lung.
Staff at the surgery identified her raised heart rate and decided she needed urgent care, sending her directly to Glan Clwyd Hospital in Bodelwyddan.
However, due to long ambulance delays, she was rushed to hospital by her dad.
Read more on blood clots
When she arrived, doctors thought she was suffering from supraventricular tachycardia (SVT).
SVT causes the heart to beat abnormally fast and is, in most cases, not serious.
But she actually had sinus tachycardia, an irregular heartbeat associated with pulmonary embolism, or PE, due to deep vein thrombosis (DVT).
DVT is a condition in which a blood clot develops in the deep veins, usually in the lower extremities.
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A PE occurs when a part of the DVT clot breaks off and travels to the lungs, which can be life-threatening.
An inquest, held in Ruthin on Friday, heard doctors misdiagnosed Kayleigh and gave her the wrong medication before she later died from the PE.
What are a blood clot’s symptoms and signs?
Kate Robertson, the assistant coroner for the northeast and central North Wales, found there were “gross failures to procure basic medical attention” in Kayleigh's case, according to the .
She said the mum “would likely have survived” had she been diagnosed correctly and treated accordingly.
An electrocardiogram (ECG), a test that records heart rate, from her GP surgery showed signs of SVT.
A senior doctor later explained that "cognitive bias" affected the reading, leading to a misinterpretation of the results.
This type of bias can sometimes obscure key details, resulting in an inaccurate diagnosis.
In a statement, Dr Mark Anderton, an emergency lead consultant at Ysbyty Glan Clwyd, said that at 5.30pm on May 16, 2022, staff made him aware a patient had SVT.
How do you know you have a blood clot? Spotting the signs
Deep vein thrombosis (DVT) occurs when a blood clot forms in one of the deep veins of your body, usually in your legs.
If a blood clot breaks off from a DVT and travels to the lung, this causes a pulmonary embolism (PE). This can be fatal.
The signs and symptoms of a DVT include:
- Swelling, usually in one leg (or arm)
- Leg pain or tenderness
- Reddish/blue skin discolouration
- Leg (or arm) warm to touch
The signs and symptoms of a PE include:
- Sudden shortness of breath
- Chest pain, stabbing; that may get worse with deep breaths
- Irregular heartbeat
- A rapid heart rate
- Unexplained cough, sometimes with blood-streaked mucus
- Sweating
- Low blood pressure
Source: NHS
He said Kayleigh had had palpitations for four days.
She had become unresponsive in a hospital bed before regaining consciousness.
The inquest heard Kayleigh was given a drug called adenosine, which slows down the heart.
It was given between 5pm and 6pm but was unsuccessful, the inquest heard.
She was then given a beta blocker, which also slows the heart rate, at 6.40pm, which the family’s barrister, Sara Sutherland, called a “shocking event".
Having gone into cardiac arrest three times, Kayleigh was then pronounced dead at 1.10am on May 17.
Dr Tom O'Driscoll, who was clinical director in the emergency department at the time and investigated the case, told the inquest the GP surgery's ECG suggested Kayleigh had SVT.
That interpretation was incorrect but he didn't blame the surgery because he said the electronic interpretation can be misleading.
I hope they don't put another family through the pain we are going through and leave another family without their loved one or young kids without their mum or dad
Ian Colegate
However, hospital staff initially treated her case as SVT, not sinus tachycardia.
Dr O'Driscoll told the inquest: "It's clear it is a sinus tachycardia...it's clear it was incorrect - a misdiagnosis."
Even then, the wrong treatment was followed, the inquest heard.
Dr Venkat Sundaram, an intensive care consultant, said there was “no indication” on Kayleigh's ECG that she could have been suffering from an SVT.
Asked if he was surprised by the working diagnosis of SVT, he said: “Yes and no.
"I personally don’t rely on what the ECG says.
"ECGs have a tendency to misinterpret, as machines can."
He admitted that it is a concern that there are “a lot of factors that can interfere with how a machine can interpret an ECG”.
On the reading of the ECG result, Dr O'Driscoll added: "What's crept in is a cognitive bias - the context has been allowed to cloud to some degree the correct interpretation of the ECG.
"It's easy for assumptions to start to creep in and they can be dangerous and in this case it was dangerous and it had a very significant outcome."
'Poor choice' of drugs
The expert also said aspects of communication among staff in Kayleigh's case “weren’t great”.
He said the beta blocker had been a "poor choice" of drug for someone like Kayleigh with a large PE.
Ms Sutherland asked him if the beta blocker was in fact the "wrong" drug.
He replied "yes", and said neither adenosine nor the beta blocker drug were necessary.
Coroner Robertson found Kayleigh died from a PE due to DVT.
She concluded Kayleigh's death was due to natural causes contributed to by neglect.
She said there is no need for a prevention of future deaths report.
But she added she would be writing to Kayleigh's GP surgery "to raise their awareness of what has been identified and to understand what learning and change has come about as a result of this incredibly sad case".
After the hearing widower Ian Colegate said: "I just really hope that Glan Clwyd Hospital have learned from their mistakes.
"I hope they don't put another family through the pain we are going through and leave another family without their loved one or young kids without their mum or dad."
Ian previously described his wife as "beautiful".
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"She was loved by so many and will leave a hole in all our lives that we will never fill.
"Her kindness, humour and fun for life will live on in our memories."
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