Coroner finds Daphne Alcantara’s death last June could have been prevented were it not for neglect in London hospital

A London coroner has found the death of dementia campaigner Daphne Alcantara on the 4th of June 2024 was preventable.

The coroner says there were “multiple missed opportunities” at University College Hospital amounting to neglect.

Initial surgery 

The 65-year-old dementia campaigner needed surgery to remove a benign tumour (an acoustic schwannoma) in her brain.This surgery was deemed a success but there were deficiencies in her aftercare, when a post-op thrombosis developed in her sinuses. A series of missed opportunities led to catastrophic brain injury.

Daphne was left in a significantly weakened state, developing hospital acquired pneumonia and sepsis. In accordance with her own advance decision, 13 days after her initial operation her family asked for life support to be withdrawn and she died.

The cause of death was recorded as “unknown” and an inquest ordered.

The inquest

Through Amy Anderson of Russel-Cooke Solicitors and Rory Badenoch of 1 Crown Office Row chambers, Daphne’s family submitted that staff at the National Hospital For Neurology and Neurosurgery failed to prescribe and administer appropriate anticoagulation medication - to help prevent blood clots - in accordance with a clearly documented plan.

They said staff had documented medication as having been given when it had not been. That staff failed to read and act upon the recommendations of a neuroradiologist. And, that they failed to investigate, diagnose and treat the thrombosis in a timely manner.

Coroner Dr Richard Ian Brittain set aside two days for the matter at the St Pancras Coroner's Court. Having heard evidence from Daphne’s husband Jimmy, as well as the medical professionals involved, he reached his conclusions after the first day.

The Coroner’s findings

The Coroner said there were multiple missed opportunities to act on imaging, which highlighted this potential diagnosis and also to initiate medication. Dr Brittain concluded that had these opportunities been taken, they would likely have slowed the progression of the thrombosis and prevented Daphne’s death from occurring on the 4th June 2024.

He found that the thrombosis was not adequately investigated, diagnosed or treated in a timely manner. And that this reflected a low standard of care, a “gross failure”.

Dr Brittain said the combined consequences of these missed opportunities amounted to neglect, which contributed to her death. 

Gone too soon, with lots still to give

Daphne poured her all into campaigning on behalf of those living with dementia and their families, believing if we could get dementia care right, there would be

significant benefits across the health and care sectors more generally.

Faced with a major threat to her own health, she was still thinking of and working for others until the end. The night before her brain surgery, she was dealing with correspondence for the charity she spearheaded, the Gibraltar Alzheimers and Dementia Society.

Those who worked with her said Daphne gave so much of herself but she still had a lot to give. Their sense of loss is now compounded by the Coroner’s finding that her death on June 4th last year was preventable.

Her family told GBC they will now make a negligence claim against the healthcare provider.

“If just one life is saved”: family statement

Daphne’s husband Jimmy Alcantara has told GBC he hopes this will raise awareness of the impact clinical negligence has on families.

He says everyone talks about this but very little is done.

Mr Alcantara hopes medical professionals will take heed. He told us: “… if one life is saved as a result, I will have done Daphne justice.”