Coroner warns NHS 111 after Camden woman's death

An assistant coroner has issued a warning to NHS England regarding its triage systems after the death of Mulu Yohanes, 53, from complications following brain surgery. Ms Yohanes died in February 2025 from pneumonia, a stroke, and seizure, brought on by low sodium levels after an operation to remove a non-cancerous brain tumour.

Ms Yohanes underwent minimally invasive brain surgery at University College London Hospital (UCLH) in Camden weeks before her death. Clinical staff at UCLH had advised her upon discharge that vomiting would be a "red flag" symptom requiring urgent medical attention.

Advice from NHS 111

Three days after her discharge from UCLH in January 2025, Ms Yohanes began experiencing intermittent vomiting. Her son contacted NHS 111 and was advised that she should treat the symptoms at home. The following day, he made another call and was told that if the vomiting continued, she should attend A&E.

Two hours after this second call, Ms Yohanes was found unresponsive. By the time paramedics arrived, she was in cardiac arrest. Although resuscitated, doctors discovered critically low sodium levels and "irreversible" brain damage due to oxygen loss. She died on February 25, 2025.

Coroner's concerns and NHS review

Assistant Coroner Melanie Lee stated it was impossible to determine if earlier flagging of complications would have prevented Ms Yohanes' death. However, she wrote to NHS England warning that potential flaws in the 111 service could endanger lives. The coroner noted that Ms Yohanes' surgery had been incorrectly recorded as a "head injury" during her emergency call.

The coroner also pointed out that the call handler had not asked if Ms Yohanes had received "discharge, worsening or red flag advice" from the surgical team at UCLH. This, the coroner concluded, may have prompted Ms Yohanes to review her written discharge instructions.

The London Ambulance Service recommended that NHS Pathways, the clinical support system used by the health service, include prompts for neurosurgery under categories such as "head injury" or "vomiting". NHS England, while expressing condolences, stated its triage tool is not diagnostic and works by ruling out more serious causes. The health body added that call handlers receive training on recent hospital discharges.

NHS England has agreed that Ms Yohanes' vomiting should not have been assessed as relating to a "head injury". In light of this case, the health service is reviewing its training for call handlers to ensure they consider post-operative instructions when assessing callers.