An inquest into the death of a 22-year-old woman has produced a detailed narrative conclusion on the interplay between chronic substance misuse, complex urological disease, and acute sepsis. The coroner determined that death resulted from septic shock secondary to a urinary tract infection, with material contribution from long-standing ketamine misuse. The proceedings also examined alleged deficiencies in clinical assessment—most notably the failure to identify an early pregnancy—while ultimately finding that such omissions did not meet the legal threshold for causation.
Factual Matrix
The deceased, Zoe Tighe, had a documented history of prolonged ketamine use. By early adulthood she was suffering severe lower urinary tract pathology, including ulcerative bladder damage, incontinence, and recurrent infections. The evidence disclosed that her condition had progressed to chronic pain of such intensity that she ceased employment and, at times, relied on a wheelchair.
Between late April and early June 2023, Ms Tighe presented to hospital on four occasions over a six-week period, each time complaining of lower abdominal pain. She was treated for presumed urinary tract infections and prescribed antibiotics. No pregnancy test was performed during these attendances.
On 24 June 2023, she collapsed at home and was admitted in extremis. Cross-sectional imaging revealed a severe renal infection and, unexpectedly, a pregnancy of approximately 14 weeks’ gestation. It was further established that the foetus had already died in utero. A diagnosis of sepsis was made. Following transfer to a tertiary centre, labour was induced. Despite intensive treatment, Ms Tighe suffered multiple cardiac arrests and died shortly thereafter.
Jane Tighe described how her daughter had been diagnosed with bladder fibrosis, known as 'ketamine bladder', and suffered frequent UTIs.
“Although she sought help, joining support groups, speaking to her support worker and seeing the GP frequently to get pain relief – the pain was relentless. She found the only thing that gave her temporary relief was ketamine, which led her to relapse.”
The court heard that the pain was so severe that it resulted in her becoming wheelchair bound and suicidal on occasion. Jane said this meant she had many visits to the emergency department at the JPH, where she claims her daughter was 'barely looked at'.
She said:
Expert Urological Evidence
Independent expert evidence was provided by Dr Krishnan Anantharamakrishnan, a consultant urologist with specialist expertise in complex bladder disorders, including ketamine-induced uropathy. As a consultant, he would ordinarily hold a primary medical qualification (MBBS or equivalent), higher surgical training culminating in a Fellowship of the Royal College of Surgeons in Urology (FRCS Urol) or comparable accreditation, and specialist registration with the General Medical Council. His clinical practice encompasses the management of advanced bladder dysfunction, reconstructive procedures, and the sequelae of substance-related urological injury. He also has experience in medico-legal reporting and in giving evidence in coronial proceedings.
Dr Anantharamakrishnan’s opinion was that Ms Tighe had developed stage three ketamine bladder syndrome, the most severe form of the condition. At this stage, the bladder becomes markedly contracted and non-compliant, with a consequent rise in intravesical pressure. This pathophysiology promotes vesicoureteric reflux, whereby urine is forced retrogradely toward the kidneys. The resulting stasis and reflux substantially elevate the risk of ascending infection and pyelonephritis, creating a recognised pathway to sepsis.
He further explained that, while major reconstructive surgery may in some cases ameliorate symptoms, the efficacy of such intervention is significantly compromised by ongoing ketamine use. In addition, the chronic pain associated with advanced ketamine bladder is often refractory to conventional analgesics, complicating both management and compliance. In his assessment, the underlying uropathy constituted a critical predisposing factor to the fatal septic process.
Issues of Clinical Management
The inquest scrutinised the adequacy of the clinical response during Ms Tighe’s earlier hospital attendances. In particular, the absence of pregnancy testing was identified as a missed diagnostic opportunity. Evidence was also heard that clinicians had focused primarily on her known ketamine-related condition, raising concerns—articulated by the family—of diagnostic overshadowing.
Notwithstanding these concerns, the coroner concluded that, although the pregnancy might reasonably have been identified earlier, this omission did not cause or materially contribute to death. There was no evidence of infection involving the foetus, placenta, or birth canal. The septic process was instead attributable to the urinary tract infection arising in the context of severe ketamine-related bladder disease.
Causation and the Legal Test
In reaching a narrative conclusion, the coroner applied well-established principles of causation. Even where a breach of duty may be identified, liability requires that the breach made a material contribution to the death. On the evidence, the court was not satisfied that earlier recognition of pregnancy would have altered the clinical trajectory or prevented the fatal outcome.
This approach is consistent with orthodox authority on expert evidence and causation, including National Justice Compania Naviera SA v Prudential Assurance Co Ltd (The Ikarian Reefer), which underscores the primacy of independent, objective expert opinion in assisting the court. The expert’s role is not to advocate, but to elucidate the medical mechanisms and probabilities upon which legal conclusions depend.
Procedural and Systemic Learning
Although the coroner rejected a causal link between the missed pregnancy and the death, the inquest identified areas for procedural improvement. The treating hospital has since implemented changes, including routine blood testing for pregnancy in women of childbearing age presenting with compatible symptoms. Such measures are intended to enhance diagnostic completeness and reduce the risk of oversight in complex presentations.
The case also highlights the challenges inherent in managing patients with chronic substance misuse. Ketamine-related uropathy is a relatively recent clinical phenomenon, but one with severe and often irreversible consequences. Its presentation may dominate the clinical picture, potentially obscuring co-existing conditions unless a structured and holistic approach to assessment is maintained.
The Role of Expert Evidence
The contribution of Dr Anantharamakrishnan was central to the inquest’s understanding of causation. By explaining the natural history of ketamine bladder syndrome and its capacity to precipitate severe infection, he provided the evidential bridge between the deceased’s long-term drug use and the acute septic event. His analysis enabled the coroner to distinguish between coincidental findings—such as the pregnancy—and the operative cause of death.
Experts in coronial proceedings are bound by a duty to the court that transcends any obligation to the instructing party. Their evidence must be impartial, within the scope of their expertise, and based on a transparent evidential foundation. In this case, the expert’s conclusions were grounded in established urological principles and consistent with the clinical findings.
By Edward Price
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