A mother-of-one planning her dream woodland-themed wedding died after having seizure in her kitchen - but a doctor's letter lost at a hospital was a missed opportunity to save her life, a coroner ruled.
Charlyne McGuire, from High Wycombe, was found slumped on the kitchen floor at their Leigh Place home by her heartbroken fiancé. The mother had suffered an epileptic fit before her body went into cardiac arrest for more than 40 minutes - less than a fortnight after turning 34 years old.
The coroner heard how paramedics "miraculously" revived her and Charlyne was rushed to hospital where she tragically died five days later - leaving behind the love of her life, fiancé Richard Shaw and her 16-year-old daughter.
The inquest heard that the young mum started having seizures out of the blue in November 2018 where she was diagnosed with an aggressive form of epilepsy as doctors pondered over the mystery cause which was never solved.
Charlyne - known to friends as Charlie - had three fits in 2018 and the same number in 2019. However, at the start of 2020, the mother-of-one had suffered nine seizures in just a few months - before the fatal fit on July 12.
During this time she had been attending consultations with Dr John Wade who saw her six times and prescribed her medication. Having tried everything he could think of, the doctor of 46 years’ experience, decided to write a letter to his colleague - an epilepsy specialist - to ask for his advice as the medication wasn’t working.
The coroner was told that at this time, the UK had just embarked on a national lockdown due to the coronavirus pandemic and the doctor was working from home.
On Tuesday, at the inquest, Dr Wade explained that whereas he would usually speak to his colleague and seek advice in the hospital, he was encouraged to write a formal request.
"I dictated a letter to Dr Chinthapalli and a secretary typed it out on May 1," he said.
"I was expecting it to be directed to the doctor so that he could advise. I first realised that the letter had not been received when I heard of her demise," Dr Wade said.
The inquest in Reading was told that a copy of the letter was sent to Charlie, to her GP and was uploaded to the hospital system but a printed copy never landed in the referral tray for Dr Chinthapalli.
Questioning the doctor, assistant coroner Ian Wade said: "Do you feel you could comment on the fact that if your letter had reached your colleague as you had intended it to, that the outcome might have been different for Charlie?"
Dr John Wade - no relation to the coroner - said: "It might have been different... It is a very unusual outcome, it was terribly unexpected."
The inquest also heard that after having unusual repeated fits, "stressed" Charlie rang the hospital and allegedly left a voicemail message chasing her doctors for answers, but the messages were never answered.
Coroner Mr Wade QC ruled that in the seven weeks between the letter being written and her sudden death, there were two missed opportunities to help Charlie.
The inquest heard that just after 9am on July 12, 2020, finance Richard Shaw found Charlie slumped in the kitchen with blue lips. In a panic, he rushed to get his neighbour to help with CPR before emergency services arrived.
Paramedics took over and rushed her to the intensive care unit at Wexham Park Hospital, where she was placed in a medically-induced coma for 24 hours.
Brain scans showed that Charlie had suffered "severe" brain swelling and after consultations with the family, her treatment was withdrawn and she died a few minutes after midnight on July 17 last year.
Following a post-mortem examination, a pathologist confirmed that Charlie died from hypoxic brain injury due to a cardiac arrest as a result of an epileptic seizure.
Concluding a narrative conclusion, assistant Berkshire coroner Mr Wade said: "If that letter had been seen on or about May 2, I think it quite likely that Dr Chinthapalli would not have disregarded it.
"He would have noted she was already in the hands of an experienced colleague and he would ordinarily have expected to give her an outpatient appointment in about four to five months.
"But he would have given the advice Dr Wade was asking for. I am satisfied that he would have recommended increasing her dosage. Understandably, the doctor was wary in his evidence of offering statistics about how much better her chances of survival would have been but at the very least, she lost an opportunity.
"I form the view that there were two missed opportunities to give advice and give additional medication."
In an online tribute, her friends and family described Charlie as a middle child who had grown up in High Wycombe and enjoyed attending cadets as a teenager, before working at a pet shop and McDonald’s.
They said: "In July 2004 one of Charlie’s greatest achievements was when she became a mum to Sky-Marie. She attended Berkshire College of Agriculture where she would juggle being a mum and furthering her education and studied childcare.
"During her time at her college she would meet Richard through a friend and it was not love at first sight, in fact she was trying to set him up with one of her friends so they could go on double dates.
"It was not until Richard went to America that they started to chat more frequently online and he made a promise to take her out for a date and see how it goes and well, it obviously worked as they continued their relationship and Charlie fell in love with him and loved the fact that he was so good with Sky."
The friends told of Charlie’s greatest passion which was caring for the elderly and vulnerable, working at the Sunrise retirement home after college - before realising her childhood dream of owning her own business.
"After some months together Richard made the bold move to ask for Charlie to marry him and she was over the moon but what he did not realise was that Charlie had already started making plans for their wedding and she was so excited and looking forward to her woodland-themed wedding.
"They had picked out their music for the wedding and together one of their favourite songs which they chose for their first dance.
"Charlie has achieved so much in such a short amount of time and lived her life to the full. She would always do everything she can to help the people she loved the most, she was always a bubbly happy go lucky character who had a heart of gold and she may be gone but she will forever be in our hearts."
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