Inquest into the death of June Nutter

58y · Female·lymphangitic carcinomatosis leading to hypoxaemic respiratory failure and cardiac arrest

June Nutter, a 58-year-old woman presenting with weight loss, anorexia, and unexplained shortness of breath, underwent gastroscopy and colonoscopy at a private hospital to investigate suspected gastric pathology. She had hypoxaemia (oxygen saturations 90% on room air) preoperatively. Though the procedure was reasonable, she was admitted to HDU where care had deficiencies: incomplete vital sign documentation overnight, nursing staff left her unattended on 20 December 2015, and during resuscitation following cardiac arrest, adrenaline was not administered per guidelines and airway management issues occurred. She died of lymphangitic carcinomatosis, a rare gastric cancer undiagnosed ante-mortem. Experts agreed the resuscitation deficiencies did not affect outcome; she died from natural disease progression. The coroner found early hospital transfer was not definitively required, though better monitoring and adherence to ALS protocols would represent optimal practice.