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The inquest into Ms Yohanes\u2019s death was held at St Pancras Coroner\u2019s Court in July 2025. Photo: LDRS<\/p>\nThe inquest into Ms Yohanes\u2019s death was held at St Pancras Coroner\u2019s Court in July 2025. Photo: LDRS<\/p>\n
A coroner has issued a warning over NHS triage systems after the death of a North London woman from complications following surgery.<\/p>\n
Muluembet \u201cMulu\u201d Yohanes, 53, died in February 2025 from complications from minimally invasive brain surgery she underwent weeks before. An inquest into her death concluded that she died from a combination of pneumonia following a stroke and seizure, brought on by low sodium levels following the operation to remove a non-cancerous brain tumour.<\/p>\n
Yohanes began experiencing intermittent vomiting three days after she was discharged from the National Hospital for Neurology and Neurosurgery, part of University College London Hospitals (UCLH), in Queen\u2019s Square, London Borough of Camden in January 2025. <\/p>\n
Clinical staff had advised her upon discharge that any vomiting would be a \u201cred flag\u201d and would need urgent medical attention.<\/p>\n
The next day, after her son called 111, he was advised that she treat the symptoms at home. He placed another call the following day and was told that if she continued vomiting she should come to A&E.<\/p>\n
Two hours later that morning she was found unresponsive, and by the time paramedics arrived she was in cardiac arrest.<\/p>\n
Yohanes was resuscitated, but after being taken to North Middlesex University Hospital doctors found her sodium levels were critically low and the loss of oxygen to the brain had given her \u201cirreversible\u201d brain damage. She died at the intensive care unit on 25 February.<\/p>\n
Assistant Coroner, Melanie Lee, said it was likely Yohanes had suffered a seizure but it was impossible to say if, had the complications had been flagged earlier, her death could have been avoided. But the coroner has since written to NHS England warning that potential flaws within the health service\u2019s 111 service could put lives at risk.<\/p>\n
The coroner noted that the person handling Yohanes\u2019s emergency call incorrectly recorded her surgery as \u201chead injury\u201d, and warned that she had not been asked if she had been given \u201cdischarge, worsening or red flag advice\u201d by the surgery team at UCLH.<\/p>\n
\u201cHad they done so, this may have prompted Mulu to review the written discharge advice she had been given,\u201d the coroner concluded.<\/p>\n
The London Ambulance Service told the coroner it had recommended that NHS Pathways, the clinical support system used by the health service, includes prompts for neurosurgery under the category of \u201chead injury\u201d or \u201cvomiting\u201d. This prompted the coroner to advise that NHS Pathways should indeed include neurosurgery, rather than leave it for call handlers to choose the most \u201cappropriate pathway\u201d.<\/p>\n
However NHS England declined to make this change. While expressing deep condolences for Yohanes\u2019s death, the health body said its triage tool was \u201cnot diagnostic\u201d and only worked by ruling out more serious causes of symptoms.<\/p>\n
The health service explained that NHS Pathways deliberately does not reference specific conditions because there are already questions to identify symptoms that \u201cindicate onward need for care\u201d, such as confusion, drowsiness and abnormal responses. The health body added that all health advisors using the triage system have to complete training for using the call line, including guidance on what to do in the case of recent hospital discharge.<\/p>\n
However, the NHS agreed with the coroner that her vomiting should not have been assessed as resulting from a \u201chead injury\u201d. In light of Yohanes\u2019 case, the NHS is reviewing the training for one of its pathways to make sure call handlers consider if callers have been given post-op instructions.<\/p>\n
Muluembet Yohanes: Prevention of future deaths report.<\/a><\/p>\n