Hospital blamed for young woman's death after she swallowed four pens

Colchester General Hospital
-Credit: (Image: East Suffolk and North Essex NHS Foundation Trust)

A 21-year-old woman who died after she swallowed four pens could have been saved if medics had treated her sooner, a damning report has found. Chloe Hunt died on March 15, 2022, at Colchester General Hospital from complications four days after swallowing four pens.

But a prevention of future deaths report has criticised the hospital trust for a lack of urgency and a “lack of recognition of her deteriorating clinical condition”. An earlier inquest had ruled that "Chloe’s death was avoidable had the pens in the stomach and duodenum [part of the small intestine] been removed earlier, Chloe would not have died when she did."

Ms Hunt, who had a history of mental health illness, was admitted to hospital on March 11, 2022, after which an initial CT scan identified three pens - one of which was impacted in her small intestine and two in her stomach. But there was a delay, partly due to her history of severe trauma and self-harm that meant she could not cope in hospital. Her mental health condition was not factored into a plan for treatment, coroner Sonia Hayes said in a prevention of future deaths report.

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Two pens were eventually removed but was not possible to remove the impacted pen. A remaining pen in Chloe’s stomach also became impacted during the interval between the gastroscopy and her death. The coroner said there was a lack of consideration of the complexities of removal to guide whether the removal should be endoscopic or surgical. This was under the background that endoscopy could not be converted into a procedure under anaesthetic in the interventional radiology suite.

She added: “The requirement for reintubation after each pen removal and the difficulty for a patient to tolerate multiple procedures without anaesthetic was not considered for Chloe on referral for removal, or whether this might need to be converted to a procedure under anaesthetic.”

Chloe was referred to the surgeons and was due to undergo a procedure on March 15, 2022. Chloe was last seen responsive around 3.45am. Chloe had largely been tachycardiac - an unusually fast heartbeat - throughout her admission with low pressure and her oxygen saturations fell during the night requiring oxygen.

Chloe was found in cardiac arrest at approximately 5.50am having suffered a cardiac arrest.

She added: “There was a lack of urgency in treating Chloe and lack of recognition of her deteriorating clinical condition. Chloe was tachycardic throughout her admission with low blood pressure and there was no investigation of the underlying cause in a young otherwise physically healthy woman.”

Dr Angela Tillett is Chief Medical Officer at East Suffolk and North Essex NHS Foundation Trust, the organisation which runs Colchester Hospital.

Dr Tillett said: “Our deepest sympathies go out to Chloe’s family for their loss. We welcome the Coroner's report and take the concerns raised in it very seriously. The Trust's full response to those concerns will be shared with the Coroner in due course. We are, however, committed to take forward any lessons learned from Chloe's death to better our processes and services.”