Inquest into the death of MQ

55y · Female·acute necrotising bronchopneumonia

MQ, 55, died of acute necrotising bronchopneumonia on 2-3 March 2023. She had developed community-acquired pneumonia from 21 February 2023, presenting initially with referred shoulder pain (later recognised as diaphragmatic irritation), progressing to dyspnoea, malaise and cough. She attended two telehealth GP appointments but did not receive face-to-face assessment or investigation despite colleagues expressing serious concern for serious cardiopulmonary pathology. Critical clinical lesson: MQ's symptoms were consistent with severe bronchopneumonia yet she was not escalated for urgent in-person assessment; GPs should have insisted on face-to-face evaluation given dyspnoea and hypoxia risk. Police delay in welfare check (8:29pm 2 March to 8:05am 3 March) prevented potential early hospital admission; though not certainly preventable, admission would have enabled IV antibiotics and oxygen therapy that might have materially altered disease progression.