Wednesbury charity supporter died of respiratory failure after not being given correct treatment, inquest told

The inquest into the death of Michelle Dawes concluded at Black Country Magistrates Court in Oldbury on April 15, with her husband Nigel and daughter Kaitlyn in attendance.

The 55-year-old, who was well-known as a supporter of Smile for Joel, had been taken to the emergency department at Walsall Manor Hospital with an ongoing cough, shortness of breath and a number of other respiratory issues on June 8, 2025.

She was diagnosed with community acquired pneumonia and given antibiotics and plan to have repeat chest x-rays six weeks later, but returned on July 8 with worsening symptoms and was found to have what was described as a large right-sided pleural effusion.

Witness statements about the treatment Ms Dawes received in her time at the hospital, including how on the night of her death on July 14, she had suffered a cardiac arrest and been transferred to intensive care, but died after two further cardiac arrests.

As well as statements, the court also heard from director of respiratory and oncology services Dr Kutaeba Ibrahim, who underwent questioning from the coroner Isobel Thistlethwaite and solicitors for the family and for the NHS into different areas of the case.

This included high International Normalised Radio (INR) levels for blood and the guidelines and protocols for chest drains, with it having been established that Ms Dawes had fluid on her lungs and had required a chest drain.

He said that he also strongly believed that if Ms Dawes had received earlier diagnostic and treatment procedures, including the chest drain, the outcome would likely have been very different.

He also said that there was a learning pathway being implemented by the Royal Wolverhampton NHS Trust and a range of steps being brought in to train staff and update the Trusts guidelines and offered his own sincerest apologies to the family for their loss, saying that they would learn from mistakes made.

Ms Thistlethwaite ruled Ms Dawes had died from respiratory failure and said it was unlikely that she would have died when she did had a chest drain been inserted in the seven days she was in hospital prior to her death.

She also said that she was concerned that the guidelines and work by the NHS Trust had not yet been implemented 12 months after Ms Dawes death, describing it as an untenable situation and ordering that a Regulation 28 order would be sent out in due course.

A Regulation 28 report, or Prevention of Future Death (PFD) report, is issued by a coroner in England and Wales when an investigation reveals action should be taken to prevent future deaths. Recipients (persons, organizations, or authorities) have a statutory duty to respond within 56 days, outlining actions taken or a timetable to do so.