An inquest has heard how Laura House, 29, was repeatedly discharged from Great Western Hospital in Swindon with migraine medication before a rare colloid cyst on her brain went undiagnosed until it was too late.
Laura House, a 29-year-old pharmacy dispenser from Cricklade, died after attending Great Western Hospital (GWH) three times in as many days in July 2024 with worsening headaches, blurred vision and vomiting, only to be sent home each time with migraine medication. An inquest, held in Salisbury before HM Area Coroner for Wiltshire and Swindon, Ian Singleton, has heard that a rare colloid cyst on her brain went undetected despite her deteriorating condition, and that she died in hospital on 11 July 2024, leaving behind her husband, Chris, and their two young children.
Three visits, no scan
Ms House first attended GWH’s urgent care centre on 7 July 2024, returning on the morning of 9 July and again that same evening, by which point her husband said she was so weak he had to carry her across the car park. On each occasion she was examined and discharged without a CT scan or further investigation. The inquest heard that, unlike a typical migraine, her symptoms grew progressively worse over the following days rather than easing, with vomiting, confusion and physical weakness becoming increasingly pronounced.
Mr House, a 36-year-old scaffolder, told the inquest that during the final visit his wife struggled to hold herself upright and was slipping from her chair as they waited more than an hour to be seen. He said she had vomited three times that evening alone and was walking as though she were, in his words, “not a 29-year-old woman.”
Conflicting accounts of her condition
According to Mr House’s statement, staff advised the couple to go home and sit in a darkened room, despite what he described as his wife grunting and struggling to communicate. He said medical notes from that evening showed the junior doctor who assessed her, Nilesh Singh, had judged her to be conscious, oriented and not confused, a conclusion Mr House said he found difficult to understand given how incoherent she appeared at the time, comparing her responses to those of a small child.
Dr Singh told the hearing the department was contending with a backlog following a power outage earlier that day, and said the noise and disruption in the emergency department may have been adding to Ms House’s discomfort. He said he had found no acute neurological symptoms during his assessment and that it was agreed she would be better off at home. However, he acknowledged to the inquest that “in normal circumstances, I would have considered a CT scan” had one been readily available at the time.
What the medical evidence showed
Dr Lisa Daniel, the senior doctor overseeing Ms House’s third visit, told the inquest in a statement that she had not been made aware her patient had already attended the hospital twice in the preceding days. She said that had this information reached her, a CT scan would have been considered. The inquest also heard that a breakdown in communication between departments meant senior clinicians treating Ms House on her final visit were unaware of her two earlier attendances with the same symptoms.
Peter Dobinson, a consultant at Great Western Hospitals NHS Foundation Trust who reviewed the Trust’s internal investigation into the death, told the hearing that a CT scan might have shown signs of raised pressure inside the skull, though he stopped short of saying it definitely would have detected the cyst, describing the likelihood as “a good chance” while cautioning that this remained speculative.
A rapid decline and emergency surgery
After returning home to Cricklade, Ms House’s condition worsened further the following day, drifting in and out of consciousness. Her husband said that shortly after 3pm she began dribbling and spitting as she breathed before turning blue, prompting him to call an ambulance and begin CPR. She was taken to Southmead Hospital in Bristol for emergency neurosurgery, but by that stage had already suffered catastrophic, irreversible brain damage caused by prolonged oxygen deprivation. She died the following day, on 11 July 2024, from a global hypoxic brain injury brought on by the undiagnosed colloid cyst. Mr House was left to explain to their children, then aged two and six, that their mother had died.
Understanding a colloid cyst
A colloid cyst is a rare, non-cancerous growth that typically forms in the third ventricle of the brain, an area through which cerebrospinal fluid drains. Medical experts say that although benign, such cysts can become medical emergencies if they block fluid drainage, potentially causing a rapid and life-threatening build-up of pressure inside the skull, known as hydrocephalus, along with brain swelling and, in severe cases, sudden death. Warning signs typically include persistent or worsening headaches, repeated vomiting, blurred or double vision, confusion, memory difficulties, drowsiness and problems with speech or walking.
Colloid cysts are thought to account for roughly one to two per cent of all brain tumours, and are usually detectable through a CT scan or MRI. Neurological specialists say patients who attend hospital repeatedly with worsening or changing neurological symptoms should be considered for urgent brain imaging.
Trust introduces “Jess’s Law” after Laura’s death
Since Ms House’s death, Great Western Hospitals NHS Foundation Trust has introduced a new policy known as Jess’s Law, which requires clinicians to reassess any patient attending hospital three times with the same complaint, ensuring previous attendances are reviewed before a decision to discharge is made. The policy is intended to reduce the risk of what is known as diagnostic anchoring, where clinicians continue treating a patient for an initially suspected condition even as symptoms worsen or change. The Trust has also reviewed its emergency department procedures more broadly, aiming to improve staff access to patients’ previous attendance records and to strengthen escalation processes for repeat presentations and decisions around brain imaging.
Ms House’s family have said they hope the changes introduced since her death will help ensure other patients with serious underlying conditions are identified before it is too late.
Verdict still to be delivered
At the inquest, lawyers representing Ms House’s family urged the coroner to record a narrative verdict with a finding of neglect. Lawyers for Great Western Hospitals NHS Trust argued that a verdict of natural causes would be more appropriate, on the basis that the inquest had not heard evidence establishing what the outcome might have been had a scan or further intervention taken place earlier. The inquest has been adjourned, with a verdict to be delivered at a later date.
