Lisa Gale

I am Dr Simon Fox KC, Assistant Coroner for Area of Avon

On 20 th April 2023 1 commenced an investigation into the death of Lisa Gale. The investigation concluded at the end of the inquest on 12 th November 2024. The conclusion of the inquest was Natural Causes.

Lisa developed a rare but serious condition of pregnancy Acute Fatty Liver of Pregnancy (AFLP). She attended hospital promptly and cooperated fully with the medical advice she received. Medical assessments and treatment were detailed and thorough. Despite this, and maximal therapy on intensive care, sadly she still died from this condition due to the rapid progression and severity of the AFLP and the added complication of acute pancreatitis.

During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows – (1) Blood was taken for liver function tests (LFTs) on admission before her condition was diagnosed; (2) Lisa’s LFT’s were grossly elevated (normal range in brackets) ALT 612 (10-50), bilirubin 122 (<21), creatinine 168 (45-84); (3) This was due to a potentially fatal condition Acute Fatty Liver of Pregnancy — from which she subsequently died; (4) Despite being grossly elevated, the results once obtained in the laboratory were not phoned through by the laboratory staff to the clinical staff; (5) This was because the Royal College of Pathologists’ guidelines for urgent reporting only provides for the same with levels above 750 for ALT, 300 for bilirubin and 354 for creatinine and does not provide for different reporting levels for those taken in pregnant women; (6) This is despite pregnancy specific conditions such as AFLP being potentially fatal at much lower levels of abnormal LFTs than those set currently by the Royal College of Pathologists; (7) As a result there was a delay in diagnosing her AFLP and starting appropriate treatment.

In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action.