Nikolas Clarke represented a local authority at the inquest into the death of a 42-year-old woman, LR. LR had learning difficulties but worked, drove and lived semi-independently with her parents.
In 2013, she was diagnosed with a heart problem, prescribed medication and placed under a hospital cardiology team’s care.
However, by mid-2015 she was reluctant to take her medication and failed to attend her hospital appointments.
Doctors tried to get her to restart her treatment but had little success. In 2019, the hospital cardiology department discharged her because of her lack of engagement.
By 2021, LR’s ability to care for herself declined and her GP made safeguarding referrals.
In 2022, the local authority’s learning disability partnership got involved. During a home visit, the assigned social worker became concerned about LR’s breathlessness and called her GP surgery. A paramedic followed up but judged there were no acute issues.
Subsequently, the social worker visited LR again. She also arranged an appointment to visit her with LR's GP and was arranging a care package for LR. However, LR died at home of a cardiac arrest.
Coroner’s decision
The coroner found that LR had died of natural causes. (The postmortem had shown that she died of heart failure).
There was no evidence that LR lacked capacity regarding her own care.
No report for preventing future deaths was made.