Samantha Davis, the late wife of fellow actor Warwick Davis, died after suffering a cardiac arrest hours before a hospital was planning to discharge her, an inquest in London has found.
Samantha Davis died aged 53 at University College Hospital in London on 24 March last year.
Her inquest was held at Inner West London Coroner's Court on Monday.
Senior Coroner for Inner West London, Professor Fiona Wilcox, concluded that Ms Davis died of arrhythmic cardiac arrest following complications of essential surgical treatment and from achondroplasia "complicated by spinal cord compression".
Ms Davis had been admitted to hospital on 7 February 2024 following a sudden loss of mobility in her lower limbs after a disc prolapse.
She underwent a thoracotomy - a surgical procedure where the chest wall is opened - on 20 February.
Her condition improved following a further thoracotomy on 14 March 2024 and the University College Hospital at Westmoreland Street in London was planning to discharge her, the inquest heard.
However, Ms Davis went into cardiac arrest at 11.25pm on 23 March and was pronounced dead at 0.28am on 24 March following a failed attempt to resuscitate her.
Giving her findings, Professor Wilcox said: "I am satisfied that the medical cause of death should be arrhythmic cardiac arrest and complications following left thoracotomies.
"In my view, the stress of everything together has precipitated this arrhythmic cardiac arrest in a lady who was not known to have any previous arrhythmia problems."
Professor Wilcox said Ms Davis had achondroplasia, a bone growth disorder that results in dwarfism, and that was "complicated by very severe spinal problems" requiring multiple surgeries from 2016.
The coroner said: "In my view, if this compression hadn't occurred, Ms Davis simply wouldn't have been so unwell.
"She wouldn't have needed two lots of major surgeries."
Discussing the care Samantha Davis received in hospital, Professor Wilcox said: "I have found nothing but excellent care being delivered to this lady and all of her complications were appropriately managed.
"It is frankly heartbreaking that the surgery itself was successful only for complications to arise and to cause her death."
David Lawrence, a cardiothoracic surgeon at University College London Hospitals (UCLH), said Ms Davis's condition was "progressing well" and she had a surgical chest drain removed on 19 March 2024 and a final drain removed on 23 March.
Giving evidence, Mr Lawrence said: "Very sadly, on the night this happened the original plan had been that she would be discharged home the following day.
"We had good evidence that this patient had a chest x-ray that was acceptable, very stable observations, and this patient did not bleed during the day."
Mr Lawrence said he did not believe the hospital "would have done anything differently", adding that Ms Davis was a "delightful lady".
Jillian Hartin, lead nurse for patient emergency response and resuscitation at University College London Hospitals, said staff reported being "out of their comfort zone" in relation to Ms Davis's cardiac arrest.
Giving evidence, she told the inquest: "This is a rare event at Westmoreland Street. Since 2020, we've only had 14 arrests in five years."
William Chapman, representing the Davis family, asked Ms Hartin: "Does it surprise you that resuscitation failed given that the team were on the scene quickly?"
Ms Hartin replied: "No, because I think everyone thinks resuscitation works because of television representation of it in dramas."
Ms Hartin added that the survival rate for non-shockable rhythms was "not good".
She said staff had been chatting to Ms Davis and expecting her to go home, adding: "I wouldn't expect them to be anything other than out of their comfort zone."
Following an autopsy conducted on 5 April 2024, pathologist Dr John Firth gave Ms Davis's cause of death as being due to complications of a left hemothorax, a blood collection in her lungs, following thoracotomy surgery.
Giving evidence to the inquest, Dr Firth said there was a "significant amount of blood" in Ms Davis's left pleural cavity around the lungs, adding it was unlikely to have been caused by CPR.
Dr Firth said he saw no evidence that the removal of the surgical drain caused a traumatic bleed.
University College London Hospitals' consultant anaesthetist Dr Katharine Hunt told the inquest Ms Davis did not have a "normal chest" following spinal surgery and thoracotomy.
Giving evidence, Dr Hunt said CPR could cause "extensive damage to tissues within the thoracic cavity", adding that Ms Davis had undergone "very prolonged CPR".
Mr Chapman said Ms Davis had phoned her family at 10pm on 23 March and complained of "chest pain".
He added that the family believed she had suffered a "similar episode" the last time she had a surgical drain removed and also raised concern about an "intense physio session" conducted hours before her death.
Mr Chapman said it was "not ideal" Ms Davis's treatment was split between University College London Hospitals' centres at Westmoreland Street in Marylebone and Queen Square.
While receiving his British Academy of Film and Television Arts (BAFTA) Fellowship award in February, Star Wars and Harry Potter star Warwick Davis dedicated the honour to his late wife.
Samantha and Warwick Davis met on the set of George Lucas's film Willow and married three years later in 1991.
They co-founded the charity Little People UK in 2012 to help individuals with dwarfism and their families. She also featured alongside him in the final Harry Potter film, 2011's Harry Potter and the Deathly Hallows - Part 2.
In a statement to the BBC in April 2024, Warwick Davis said of Samantha Davis's death: "Her passing has left a huge hole in our lives as a family. I miss her hugs."
He said that his late wife was his "most trusted confidant and an ardent supporter of everything I did in my career".
The actor continued: "She was a unique character, always seeing the sunny side of life. She had a wicked sense of humour and always laughed at my bad jokes."
The couple's two children, Annabelle and Harrison, also paid tribute to their mother, saying: "Her love and happiness carried us through our whole lives."
"Mum is our best friend and we're honoured to have received a love like hers," they added.
Source: Press Association
