'Chloe had so much to give': Mother speaks out at inquest into her daughter's death after a severe asthma attack

The inquest held at Oldbury on Tuesday heard that the 25-year-old Walsall Manor Hospital ward clerk who had a history of asthma also had a dental abscess and was 10-weeks pregnant. 

She was was correctly prescribed a nebuliser and antibiotics and then sent home.

However, Assistant Black Country Coroner Mr Michael Pemberton told the hearing that a hospital investigation found Miss Arnold was not given a peak expiratory flow test which measures how quickly patients could blow air from the lungs despite it being part of assessment procedures.

Giving evidence urgent care locum Dr Emeka Nzenwata explained that the emergency department and the urgent care department used different assessment systems and when he treated her, he was unfamiliar with a checking system which would have flagged that she required a peak flow test.

Dr Nzenwata said: "I was always aware of peak flow. At the time I saw her the evidence was pointing to a mild case of asthma exacerbation."

He added that since the incident he now gave all asthma patients he treated the test.

The inquest was also told that a root cause analysis of the case had been carried out by Walsall Healthcare Trust and the urgent care operator Malling Health resulting in changes in asthma care.

Mr Pemberton said: "I find there were missed opportunities in regard to her status as a pregnant lady which would have lowered the threshold for admission to be considered. She was discharged."

He said later that evening she became short of breath and suffered cardiac arrest resulting in the ambulance service being called to her Lowe Avenue home in Rough Hay by her mother. She was given CPR by relatives and paramedics before being taken back to the hospital where she died on March 9.

"On the balance of probabilities it cannot be said that had she remained in hospital that her death would not have happened. I heard clear evidence of the deterioration in her condition when she went home.

"I am satisfied with the evidence heard from the ambulance service that the triage and treatment given by its staff was appropriate.

"In my judgement this was a natural death and while also noting while there was some suboptimal care and missed opportunities, they did not contribute more than minimally to Chloe's death, "  Mr Pemberton said.

The medical cause of death was given as lack of oxygen to the brain, acute severe asthma, asthma and pregnancy.

Giving evidence her mother Sarah Porter told the hearing that her daughter was diagnosed with asthma at 18-months and was not always organised in taking her medication and sometimes misplaced her inhalers. She said Miss Arnold's condition got worse throughout her lifetime.

Ms Porter said: "She was full of life. She had so much more to give and we all miss her every single day. I hope that things will be put into  practice with the peak flows so that no-one else will has to go through what I am going through."

She also said Miss Arnold did not tell her she was expecting a baby because she and her boyfriend were saving the news for Mothering Sunday.

Mr Pemberton recorded a conclusion that Miss Arnold death was due to natural causes.

Chloe,  was also survived by sisters Mercedes, 24, and Ellie Mae, 12, brother Henley, 13, dad Wayne Arnold, of Willenhall.

Her colleagues on ward two at the hospital held a minute’s silence in her memory to coincide with a balloon release at George Rose Park, in Wolverhampton Street, Darlaston, which was attended by dozens of well wishers.