Young woman died after routine heart procedure in Sussex; coroner could not 'contemplate the grief' of parents who also lost son in airshow disaster

Louise Schilt, 34, died at home at The Close in Brighton, on April 5, 2023, having had a chest drain procedure at the Princess Royal Hospital in Haywards Heath, for pleural effusion earlier that day.

Her brother, Jacob, was among the 11 men who were killed in the Shoreham Airshow disaster on August 22, 2015.

Louise first reported problems relating to her breathing around Christmas time in 2021, the inquest heard.

Her medical cause of death was I(a) re-expansion pulmonary oedema, (b) drainage of pleural fluid, (c) constrictive pericarditis owing to chronic fibrosing pericarditis.

HM senior coroner for West Sussex, Penelope Schofield, said: “The underlying cause of the pericardial disease remains unclear. Louise underwent a chest drain to relieve the symptoms of her condition during which she suffered a rare complication from the procedure from which she died.

“Unfortunately there had been a delay of over seven months in Louise having the necessary diagnostic procedure of a cardiac MRI to enable those treating her to reach the correct working diagnosis.

"During this period, there were a number of missed opportunities to escalate her care and therefore treat her before there was an acceleration of the disease process. She died before she was able to be given any definitive treatment.”

Ms Schofield stressed during the inquest in Horsham that it was ‘not a court of blame’ but it was ‘necessary to investigate negligent actions that may be necessary to Louise's death’.

She added: “I propose to record Louise's death as a narrative conclusion.

"She was only 34-years-old – a much loved daughter to Caroline and Bob Schilt.

“Her mother described her as the kindest, most caring person she had ever met. She cared so much for others more so than herself. She was selfless and loving, she cared with the whole of her heart.

“Louise had a past medical history but perhaps the only thing relevant for us to consider is she had asthma.

“Up until late 2021, Louise did not really have any major health issues.”

The court heard that Louise first sought medical attention in December 2021 after developing a cough. Louise, who had received the Moderna vaccine, tested negative for Covid-19.

Ms Schofield, reciting the evidence she had heard during the four-day hearing, said: “It got worse after Christmas and Louise was breathless and unable to walk far.

“She saw her GP in January who suggested she had a virus that triggered her asthma. She was issued with inhalers. Her cough continued and she started to lose weight.

"She saw the GP again on January 18. This time she was prescribed antibiotics and steroids and sent for an X-ray.

“This revealed Louise had a chest infection but it also showed she had an enlarged heart.

“The ECG was normal but she was also referred for cardiology for the first time. Blood tests showed she was anemic.”

Louise was also found to have an enlarged liver, the inquest heard.

After further examinations, including a CT scan, it was found she was suffering from heart failure, the court heard.

Her first cardiology appointment was on June 24 – five months since the first referral. The coroner heard of the ‘pressures on the service at the time’.

She added: “The latest echocardiogram was almost normal and [the professor] took the view she was recovering from whatever caused the heart failure.

"However, he wanted to do a cardiac MRI scan and had a 24-hour holter monitor. This was carried out in July but nothing further was heard about the cardiac MRI scan.

"We heard there was no formal follow up or monitoring procedure place. He would have reviewed Louise's case once the cardiac MRI scan took place and she was placed on a waiting list.

"This scan was not forthcoming until February 2022 – almost eight months later and it is that delay that I'm concerned about.”

In November 2022, ‘there was a change of events’, the court heard.

"Louise's cough returned and it was getting worse,” the coroner recited. “Her parents told us it came back with a vengeance.

"She went back to her GP who sent her for blood tests and then a chest X-ray.

“This revealed a right sided pleural effusion. We know the GP contacted cardiology and we know the doctor was aware of her deterioration.

"We've seen the letter he wrote to the GP in December for her to be seen urgently in the pleural clinic. This letter was dated December 9. It is my view that this was a missed opportunity to escalate the urgency of Louise's case and to expedite the cardiac MRI scan.”

On December 19, pleural fluid was drained and then a follow up X-ray took place on January 30.

The court heard Louise’s initial appointment for a cardiac MRI scan in January was then postponed but ‘it does not appear her consultant was made aware’.

"Her condition continued to deteriorate,” the coroner said. “She reported shortness of breath after minimal of exertion and her latest chest X-ray on January 30 demonstrated lateral pleural effusion.

"She still had not had her cardiac MRI scan. This was ultimately performed on February 16 which showed features consistent with constrictive pericarditis.”

The inquest heard this diagnosis was later confirmed and treatments were given but a hospital admission was not considered.

Ms Schofield added: “Louise continued to deteriorate.

“On April 1, her feet and ankles began to swell. She was breathless and clearly very unwell.

“She attended catheterisation on April 3. There was conflicting information about whether she chose not to go ahead that day or if there were problems with her lying down.

"Or, as Louise’s parents have indicated, that Louise had told them the appointment was cancelled due to emergencies.

"I cannot determine the reason but the evidence suggested this was a lady who needed urgent attention. There didn’t seem to be any urgency in rescheduling the appointment.

"She was very unwell. Consideration should have been given for her to be admitted into hospital. This would have provided the best care.”

The inquest Louise ‘didn’t like to make a fuss’ but suffered an ‘increased shortness of breath’.

She subsequently underwent further pleural drainage on April 5, 2023.

Ms Schofield said: “The drainage was uneventful and she was discharged home. Her father picked her up. She couldn’t even speak by the time she got out of the car.

"Her parents went out for a short period. They returned home to find her unconscious in the toilet.

"The emergency services arrived and carried out CPR. The ambulance service worked on but sadly were unable to revive her. Sadly she was pronounced deceased at the scene.

“She died from a rare complication.”

The inquest heard there was ‘unlikely to be any link’ between the Covid vaccine and Louise’s death.

Expert witness Professor Gershan Davis told the inquest he considered it to be an urgent cardiology case.

Ms Schofield recited: “He would be concerned as she was only 34 with heart failure. An urgent need to get investigations done.

"He said seven months, nearly eight months, was not standard and not an acceptable waiting time. She should have been on the department radar.

"He accepted a follow up appointment was not mandatory. There was a need to expedite the cardiac MRI. He said hospitalisation should have been considered.”

Ms Schofield said she was ‘not minded to write a Prevention of Future Deaths report as the issues identified in this inquest ‘appear to have been addressed’.

She added: “I’m told they have been addressed and I hope that is the case. I have to accept that on face value.

“I am however going to be writing a letter of concern to the trust.

“I was shocked – as I’m sure many of you were – when we heard the evidence from the family relating to the letters they still received letters addressed to Louise and the telephone contact that was made trying to contact Louise by the hospital after her death.

"This happened many weeks after her death. It must have been terribly upsetting and compounded the family grief.

"They do not need to be caused more pain and anguish by this lack of sensitivity. In this day and age, it is totally unnecessary and needs to be addressed by the trust.”

Directly addressing Louise’s parents after delivering her verdict, the coroner said ‘words escape me’.

She added: “I really don’t know what to say to you both other than to extend my sympathies to you for the loss of Louise in these circumstances.

"I just don’t understand how the world can be so cruel to one family. You losing Louise in short succession to the loss of Jacob.

"I can’t contemplate the grief you must be facing. What I would say is I am very grateful to you both. Despite all that has happened, you have remained so dignified during these processes.”

Paying tribute to her daughter at the time of her death on social media, Caroline wrote: “Our lovely daughter Louise has died suddenly at home yesterday, cruel enough to lose Jacob in the Shoreham air crash but now to be robbed of our our other child seems cruel beyond – the sweetest kindest girl we will always love you.”