Coroner urges PM to hold coronavirus inquiry after ruling on pregnant nurse’s death

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A coroner has called on the prime minister to press ahead with a public inquiry into the pandemic “as soon as practicable” after concluding that it’s unclear how a heavily pregnant nurse contracted coronavirus (Covid-19).


Coroner Emma Whitting delivered a narrative conclusion at the inquest into the death of sister Mary Agyapong, 28, who died last year at the Luton and Dunstable Hospital where she worked, five days after giving birth to her second child.

She spent at least the last week of her life with coronavirus, a diagnosis initially dismissed by medics at the hospital where she worked, despite collapsing at home and suffering acute breathing difficulties.

In closing the inquest at Bedfordshire and Luton Coroner’s Court, the coroner said:

I would like to express my own condolences to Mary’s family.

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Whilst Mary’s untimely death is first and foremost a tragedy for you her husband, for her children, and all her relations, colleagues and friends, it is for society too. As a society, it is important that we learn from all of the lives that have been lost as a result of this terrible pandemic and to consider the wider policy implications that may be lost from each and every one of these.

Since this is a process which goes far beyond a coroner’s inquest and the Prime Minister has indicated his intention to hold a full public inquiry into the Covid-19 pandemic, I urge him to proceed with this as soon as practicable.


The inquest began last week on the day the nation marked a national day of reflection for those who had died in the pandemic. Stating that Agyapong died of of multiple organ failure and coronavirus, the coroner said:

The deceased died after contracting Covid-19 but it remains unclear where and when her exposure to the virus had occurred.

Agyapong’s widower Ernest Boateng told the inquest that she was concerned about becoming infected at work while heavily pregnant. Luton-based Agyapong, who was originally from Ghana, died as the coronavirus case rate soared across the UK.

Ernest Boateng arrives at court for the inquest into the death of his wife
Ernest Boateng arrives at court for the inquest into the death of his wife (Joe Giddens/PA)

“Hardest pain to bear”

After the ruling, Boateng said:

The sudden death of my wife and the mother of our two children has been the hardest pain to bear. In those early days after Mary’s death, I was only able to carry on because of the need to care for our children and provide them with a loving home.

Mary was strong, capable, vibrant, full of life and the most precious person in my life. It is still difficult to believe that she lost her life to the Covid-19 virus.

I am glad that those who were involved in Mary’s care in the final weeks of her life have had to give a full account of what happened.

I hope that the fact that they have had to do so will remind them of the need to always give the best possible care to women in Mary’s situation – especially black women who are themselves on the frontline of healthcare.


Agyapong was admitted to hospital with breathing difficulties on 5 April but discharged later that day – something she was unhappy with. She was readmitted two days later with coronavirus symptoms at 35 weeks pregnant.

Surgeons safely delivered the baby, also named Mary, by Caesarean section before Agyapong was transferred to the intensive care unit on 8 April where she died four days later.

The preliminary cause of death was given as pneumonia and coronavirus.  Boateng told Bedfordshire and Luton Coroner’s Court his wife “was very concerned about the situation involving Covid-19”, and would immediately shower after coming home from work, and would also sleep in their spare room to protect her husband and young son.

Mary Agyapong with her partner Ernest Boateng
Mary Agyapong with her partner Ernest Boateng (Family handout/PA)


Boateng said he strongly believed his wife contracted coronavirus while at work, and also questioned why she was discharged from hospital on 5 April with a course of antibiotics despite having coronavirus symptoms.

Dr William Manning, who decided to discharge Agyapong on her initial admission to hospital, told the inquest he “suspected she had Covid-19”, but sent her home because she did not require oxygen.

Dr Manning claimed: “She didn’t seem particularly happy to go home”.

Other medical staff told the coroner they were satisfied with the care provided to Agyapong, and said her condition deteriorated rapidly.

Dr Deborah Shaw, an intensive care consultant who saw Agyapong the day after she gave birth, said: “I was very happy with the level of care she was getting”. Dr Muhammad Peerbhoy, a consultant physician who saw the patient the same day, added: “In my opinion, I think the treatment was proportionate”.

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