A CORONER will write to Furness General Hospital due to his concern that two women died in ‘very similar circumstances’ shortly after discharge from its emergency department.

Nancy Rogers, 75, died in her home on Ocean Road, Walney Island, on November 19 last year due to a ruptured aortic aneurysm, which caused a bilateral haemothorax, an inquest heard.

Mrs Rogers was taken to hospital in Barrow after collapsing in the town centre while shopping at around midday the day before.

She was unconscious for several minutes, according to passersby who called 999.

An ambulance report said she said she had a pain in her hips and lower back and felt dizzy.

She was transferred to the emergency department at Furness General and was seen by Mr Richard Tyson, an advanced practitioner.

He found Mrs Rogers to have low blood pressure and he said ‘by that point she’d improved’.

He said she seemed ‘lucid and chatty’ and not complaining of pain.

Having initially complained of chest pain, further investigations were carried out including a chest x-ray, revealing a pleural effusion, reduced haemoglobin levels and an increased white blood cell count.

Due to the several factors that investigations revealed, Mr Tyson sought advice from the on-call registrar Dr Chua, who then assessed Mrs Rogers.

A statement by Dr Chua was read to Cockermouth Coroners’ Court. It said Mrs Rogers showed no signs of heart failure and was not in need of pain relief but her symptoms of pleural effusion, weight loss and anaemia made her suspect a possible malignancy.

Dr Chua devised a follow-up plan for Mrs Rogers to return to the hospital for further investigations as an outpatient to investigate the malignancy with advice to return to the emergency department if any symptoms reappeared.

She said Mrs Rogers’ blood pressure had stabilised and while the follow-up plan was for ‘early’ intervention, it was not ‘urgent’.

In the early hours of November 19, Mrs Rogers was witnessed by her friend to fall on the floor while on the way to the toilet and stop breathing.

CPR was started within five-seven minutes after the collapse but Mrs Rogers showed ‘no signs of life’ and was pronounced dead.

Assistant Coroner for Cumbria Dr Nicholas Shaw highlighted the importance of raising awareness of the symptoms of aortic dissection, which had not been diagnosed during investigations, and caused Mrs Rogers' death.

Addressing Dr Chua, Dr Shaw said: “With hindsight, I can quite understand that you were looking the way you did, and you certainly organised prompt follow-ups, so I bear no criticism of what you did."

He acknowledged Mrs Rogers did not present as a typical aortic aneurysm case as this would normally be accompanied by abdominal pain

Dr Shaw said: “I have the benefit of seeing all these reports – you didn’t have that.

“You were faced with the findings on the afternoon and you made reasonable decisions, I think, based on what they were.

“With hindsight I think it would be good if we could get some learning from this.”

Concluding that Mrs Rogers died of natural causes, he said: “I do plan to send a regulation 28 report to the medical director at Furness General Hospital asking that some learning perhaps take place, given that I shall also be referring to the death of Shirley Potter, on February 12, 2023, whose inquest I heard, and she died in very similar circumstances, after attending the A and E department at Furness General, and she too had a dissecting aneurysm which was not suspected, a different diagnosis was given, and she died shortly after discharge.

“It is a condition that is potentially treatable with early diagnosis, and suspicion of the awareness of the possible diagnosis is essential.

“I was told after Shirley Potter’s inquest that there were no learning issues to be had.

“I am convinced that no learning has taken place in conjunction with this inquest either.”

Dr Shaw also quoted ‘significant’ figures from the aortic dissection trust (an organisation to raise awareness of the condition) that around one in three dissection diagnoses are missed by clinicians, around 2,000 people a year die from it, and around ten lives a week could be saved if all were correctly diagnosed.

A statement read to the court by Mrs Rogers’ daughter Marissa Asplund said that her mother was born and brought up in the Philippines and moved to London in 1986.

She was the widow of Lionel Rogers, and moved to Walney 12 years later, where she met her partner Bernie Walker.

She said she visited the Philippines every three years and ‘her children were her priority and the source of her happiness’.