The Inquest touching upon the death of Gillian Trevor
| Jurisdiction | Northern Ireland |
| Judge | Mrs Fee |
| Judgment Date | 19 April 2023 |
| Neutral Citation | [2023] NICoroner 3 |
| Court | Coroners Court (NI) |
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Neutral Citation No: [2023] NICoroner 3
Judgment: approved by the court for handing down
(subject to editorial corrections)*
Ref: [2023] NICoroner 3
Delivered: 19/04/2023
BEFORE THE CORONER OF NORTHERN IRELAND
MRS LOUISA FEE
THE INQUEST TOUCHING UPON THE DEATH OF
GILLIAN TREVOR
Introduction
1. Before I begin to deliver my findings in respect of the death of Gillian Trevor,
referred to throughout the Inquest as the deceased, I wish to offer my sincere
condolences to her family.
2. The inquest proceeded in hybrid form, meaning that a mix of remote
technology and live courtroom attendance was utilised and I am grateful to
those who attended and gave evidence to the inquest. I also utilised my
powers under the Coroners (Practice and Procedure) Rules (Northern Ireland)
1963 to admit a number of statements and records under Rule 17. I do not
intend to recite all of the evidence in these findings, but rest assured that all of
the evidence received by me has been considered before arriving at these
findings.
Inquest Evidence
3. The deceased, Gillian Trevor, of 16 Rosemary Place, Coleraine born on 13
February 1959, died on 23 September 2017 at the Royal Victoria Hospital. She
was 58 years old.
William Chestnutt, husband of the deceased, made a statement dated 5
November 2021 which was admitted to the inquest under Rule 17. Mr Chestnutt
sadly died on 23 December 2022. His statement records that, prior to the
deceased’s death, he was in a relationship with her for 43 years and they had
three children, Claire, Emma and Lee. On 18 August 2017 he and the deceased
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were at home when she failed to respond to him calling to her. He found her in
the kitchen staring into space and unresponsive when he gently shook her. He
contacted his son Lee and the out of hours doctor. His son arrived at the house
and an ambulance was tasked to attend. Mr Chestnutt recorded that his son laid
the deceased on the floor, and he noted froth coming from her mouth. When the
ambulance arrived, some difficulties were encountered in getting the deceased
from the house into the ambulance. He followed to the Causeway Hospital
where he was subsequently advised that the deceased needed a computerised
tomography scan (CT scan). Mr Chestnutt left the hospital around midnight and
was unaware of the outcome of the CT scan. On 20 August 2017 he received a
call to collect the deceased from hospital.
5. Over the course of the following week Mr Chestnutt records that the deceased
was not herself, he described her as distant and quiet. She returned to hospital
on 28 August 2017 and was discharged again. Thereafter, Mr Chestnutt noticed
the deceased’s face droop on the left side and observed her to lose power in her
left leg. She had an appointment with her general practitioner (GP) on 1
September 2017 who sent her to hospital. Mr Chestnutt recorded that he visited
her on 3 September 2017 and was unable to get any information about her
condition from nursing staff, he thought she was trailing her left leg as she was
assisted to the toilet. After he went home, he received a call at approximately
6.00 am on 4 September 2017 advising that the deceased had a CT scan and was
going to be blue lighted to the Royal Victoria Hospital (RVH). He received a call
thereafter from a doctor at the RVH who spoke to his son Lee. They were
advised to attend the RVH later that afternoon.
6. Mr Chestnutt did not feel that as the deceased’s next of kin, he was kept
updated about her condition, he was annoyed that she was not given a second
CT scan or magnetic resonance imaging (MRI) scan during her first attendance at
the Causeway Hospital and that she was not provided with any letters or
referrals on her discharge. He did not feel she was given the care and attention
she required at Causeway Hospital however he had no concerns about the care
she received at the RVH.
7. Claire Chestnutt, daughter of the deceased, gave evidence to the inquest. She
said that when she was told that the deceased had taken unwell on 18 August
2017, she made her way to the Causeway Hospital and arrived about 7.00 pm.
She recalled being told by someone in the hospital that the deceased required a
second CT scan with higher definition. She was also told on 19 August 2017 that
an MRI scan was required but couldn’t be done as the deceased’s temperature
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