Elizabeth Agbejimi

I am Paul COOPER, HM Assistant Coroner for the coroner area of Lincolnshire

On 06 July 2021 I commenced an investigation into the death of Elizabeth Oluwatofunmi AGBEJIMI aged 22. The investigation concluded at the end of the inquest on 13 June 2023. The conclusion of the inquest was that: The deceased died on 27th June 2021 at Lincoln County Hospital, Greetwell Road, Lincoln following a multiple falls that the pathologist identified as a direct cause of death.

During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: (brief summary of matters of concern) [REDACTED] gave evidence that following a venous blood gas sample undertaken on 12th June 2021 which showed a significant respiratory abnormal acidosis reading but no further investigation was undertaken. The deceased died 2 weeks later of a respiratory condition. Is this a training/communication issue?

In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action.

You are under a duty to respond to this report within 56 days of the date of this report, namely by August 09, 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed.