Family challenges GP surgery over death of domestic abuse victim

Mystery surrounds the death of a domestic abuse victim who used to be kicked and beaten by her husband, an inquest revealed. A hearing into the death of Susan Tregear was unable to come up with an explanation for her death.

Susan, 56, from Camborne, was abused by her husband in May 2022, the coroner's court was told. The violent assault against her meant that Susan required hospital treatment for a perforated bowel. As a result of her operation, the Redruth-born woman had to have a part of her intestine removed.

The inquest held in Truro today (Tuesday, May 14) was told that Susan's recovery was long and protracted as her wound kept reopening. It meant she spent nine months in hospital and a further three months in convalescence in Newquay before she moved into a new apartment in Camborne last year.

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Her sister Patricia Opie told the inquest that Susan's family were concerned that the injuries she had received at the hands of her husband may have led to her death. However the inquest heard that the post-mortem examination was inconclusive and the abuse she received a year or so before could not be linked to her later health issues.

Similarly, a toxicology report found nothing other than the medication Susan had been prescribed to take for anxiety and bowel issues.

The inquest was told that for a time, Susan was happy in her new flat and she seemed to have turned a corner with her health. Mrs Opie said that in May last year she contacted Susan's GP practice, Carn to Coast Health Centres - one of the largest cluster of GP practices in Cornwall with some 30,000 patients on its books - because she worried about Susan's condition.

She told the hearing that Susan suffered from shortness of breath and anxiety. Dr Ruth Mowlam, one of the associate GPs at the practice, told the hearing that Susan was not always taking the medication she was asked to take which probably made her mood swings worse and increased her anxiety.

Dr Mowlam told the inquest that nothing acute was found when she spoke to Susan that required an immediate home visit from a doctor or healthcare worker so it was not organised and priority was given to another patient. Susan was discovered deceased at her home the next day when her carer raised concerns with her employer that she had not been able to gain access into Susan's home and the fire service and then paramedics had to be called out.

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Mrs Opie said: "I went to the doctor so they would go and see Susan. I knew she was not right. She had breathing difficulties. She couldn't get out of bed. I wish I hadn't bothered and called an ambulance instead." Dr Mowlam told the inquest that lessons had been learnt from Susan's death including improving note-taking using the patients' or their relatives' own words when describing conditions rather than a summary of it.

Anne Hood, Susan's carer, also gave evidence at the hearing. In her statement read out in court, she said she had only been working with Susan for a short time prior to her death. She said Susan did not always take her medication or even eat even when encouraged to. She said that while Susan had a post hospital stay care plan "she would not be forced to do anything she didn't want to do".

She added: "She was reluctant to receive any care or help. She was hard to make conversation with. She wouldn't tell me if she was in pain in wanted anything." Ms Hood said Susan had not presented as unwell and certainly did not expect her to die overnight.

Returning an open conclusion, Andrew Cox, senior coroner for Cornwall and the Isles of Scilly, said Susan seemed to be on the path to recovery following her difficult hospital discharge. He said she had anxiety which was affecting her breathing which led her sister to raise concerns that her condition had been getting worse, which led Mrs Opie to ask for a home visit to be organised by Susan's GP practice. But no attendance was deemed necessary.

He said: "A process was in place for the need for a doctor's attendance to be considered the next day. Susan had not been expected to die overnight. The cause of Susan's death could not be ascertained which leads me to return an open conclusion."