Finding into death of Sarah Louise Rose
Deceased
Sarah Louise Rose
Demographics
40y, female
Date of death
2014-04-15
Finding date
2021-03-31
Cause of death
Cerebral oedema of unknown aetiology with probable contribution from Hashimoto's encephalopathy (Steroid Responsive Encephalopathy Associated with Auto-immune Thyroiditis) in a woman with untreated Hashimoto's thyroiditis
AI-generated summary
Sarah Louise Rose, aged 40, died from cerebral oedema of unknown aetiology with probable contribution from Hashimoto's encephalopathy. She had been diagnosed with Hashimoto's thyroiditis in late 2011 and prescribed thyroxine, but likely ceased taking it months before her death. Over four months preceding death, she developed headaches, dizziness, confusion and altered consciousness. Despite two hospital admissions and extensive investigations, her Hashimoto's disease and medication non-adherence were not identified. The expert conclave agreed that optimal thyroid management by general practitioners, including reinforcement of daily thyroxine adherence and regular monitoring, would have improved her health. Similarly, hospital admissions provided opportunities for comprehensive history-taking that would have identified whether she was still taking thyroxine and allowed recommencement of therapy. However, the coroner found insufficient evidence to determine the primary antecedent cause to support adverse findings against treating clinicians.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
Contributing factors
- Untreated Hashimoto's thyroiditis
- Cessation of thyroxine therapy months before death
- Hashimoto's encephalopathy/SREAT
- Failure to identify medication non-adherence at hospital admissions
- Failure to identify Hashimoto's disease diagnosis during clinical encounters
- Inadequate reinforcement of need for daily thyroxine therapy
- Inadequate thyroid function monitoring
Coroner's recommendations
- Clinicians managing Hashimoto's disease should provide regular reinforcement of the need to take thyroxine daily
- Regular thyroid function blood tests should be performed to monitor the efficacy of thyroxine treatment
- Hospital admissions should include full history-taking to identify chronic conditions such as Hashimoto's disease and medication adherence
- Enquiry should be made during hospital admissions regarding whether patients are continuing to take prescribed thyroxine and reasons for non-adherence
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