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Coroner Links Undiagnosed Tumor to Suicide
28 Jan
Summary
- Woman died six days after hospital discharge.
- Doctors failed to diagnose a brain tumor pre-death.
- Coroner cited missed diagnosis contributing to emotional state.
A woman tragically died by suicide six days after her hospital discharge, following a failure by medical staff to diagnose a brain tumor. Sarah Heaver, 59, was found unconscious and taken to QEQM Hospital in Margate, but improved and was released without further investigation.
During the inquest, it was revealed that Sarah had expressed suicidal thoughts in the weeks leading up to her death. A post-mortem examination later confirmed a large pituitary brain tumor, which had been missed by doctors and was putting pressure on her adrenal gland.
Coroner Sarah Clarke has issued a report to prevent future deaths, highlighting concerns about the lack of neurological investigations and structured observations for patients with low consciousness scores. She noted the undiagnosed tumor likely contributed to Sarah's declining emotional state.
Concerns were also raised about the accessibility of mental health support post-discharge, with inconsistent and incomplete medical records significantly hindering the investigation. Both East Kent Hospitals University NHS Foundation Trust and Kent and Medway NHS and Social Care Partnership Trust are reviewing the coroner's findings.
