'Missed opportunities' to prevent death of Kings Lynn teen

Karolina Lipodatenko died at her flat in Portland Street in King's Lynn on March 31 last year, having suffered from a pulmonary thromboembolism. She was just 18.

An inquest heard of a string of opportunities to identify the condition were missed in the days leading up to her death.

The court was told that on March 22 Miss Lipodatenko attended the emergency department of the Queen Elizabeth Hospital complaining of a shortness of breath and pain in her calf.

Medics suspected her condition may have been caused by either deep vein thrombosis or a pulmonary embolism - whereby a clot blocks the arteries to the lung - although a chest infection was also not ruled out.

She was scheduled for a CT pulmonary angiogram, a type of scan that identifies pulmonary embolism. 

However, this scan involved dye being put into her bloodstream via a cannula, which Miss Lipodatenko found painful and aborted the procedure.

She then told consultants she did not wish to undergo the scan and wanted to go home.

Giving evidence to the court, Shyan Seshadri, a consultant who spoke to Miss Lipodatenko, admitted that he had not explained the full extent of the risk of not having the scan and subsequent treatment to her when she opted out.

He said: "I was aware that she was very anxious and my explaining to her that she was at risk of dying may have made her more anxious.

"With the benefit of hindsight, I should have been more forceful. I explained to her that she would become really quite poorly, but that is not the same as saying she could die."

He added that he had not been aware of her neurodivergence when discussing the risk with her.

Dr Seshadri said that had a diagnosis of pulmonary embolism been made she would have been more likely to survive, if she accepted further treatment. 

After Miss Lipodatenko opted out of having the scan she was kept in overnight with the idea of attempting to offer it again, but after she again refused she was sent home with a course of antibiotics and a diagnosis of a suspected chest infection.

Aerial image of the Queen Elizabeth Hospital in King's Lynn (Image: Mike Page) Other missed opportunities

On March 30, Miss Lipodatenko contacted her GP complaining that the antibiotics had made no difference - and she was given a telephone appointment the next day.

She did not answer her phone and a voicemail was left for her.

At shortly after 12pm on March 31, she phoned 111. Her call was handled by Integrated Care 24, a partner organisation of the NHS which triages calls.

Through this call, she was offered a face-to-face appointment at the hospital at 6pm.

However, an audit of the call determined the handler - who has since had additional training - should have categorised one of her answers to prompts differently.

Had they done so, it would have resulted in an ambulance being sent to her home.

Just over two hours later, she was found unresponsive and despite receiving CPR, died in her flat.

Giving a narrative conclusion, area coroner Samantha Goward said: "Karolina died of a naturally occurring condition for which she declined investigation and treatment due to significant anxiety, likely linked to her autism and mental health conditions."

She said there had been "missed opportunities" for the ultimately fatal condition to be diagnosed and treated.

Tragic similarities

(Image: Courtesy of family) Miss Lipodatenko's case bears tragic similarities to that of 11-year-old Mattheus Ferreira-Vieira, who died at the QEH  in April 12.

Like the Lynn teenager, Mattheus was diagnosed with an autistic spectrum disorder which had an impact on his treatment at the hospital.

An inquest into his death heard he had been considered "uncooperative and difficult" by medics during the course of his treatment.

As a result, the hospital missed "multiple red flags" to diagnose the sepsis which eventually killed him.

During Miss Lipodatenko's inquest, it was heard that since both incidents the QEH had made several changes to improve the way it cares for neurodivergent patients and people with learning disabilities.

Among these measures, it has employed a specialist learning disabilities nurse and dedicated a specific ward which can be used for these patients.

Mrs Goward praised this measure, saying: "It is reassuring to see how much work is going into this and I am particularly pleased to hear of the specialist ward - as emergency departments can be very busy and scary places to be."