A mother died from sepsis after doctors failed to examine her despite signs of infection following a hysterectomy, an inquest has heard.
Jessica Bonner, 51, developed sepsis following delays by medics in diagnosing a perforated bowel.
She had been admitted to Good Hope Hospital in Sutton Coldfield, West Midlands, for treatment for pelvic pain and fibroids in October last year.
Bonner underwent a hysterectomy and oophorectomy – removal of her womb and ovaries – but recorded a high temperature and elevated heart rate a day later, both indicators of infection.
Her situation was not escalated to the ward consultant or surgeon, the inquest heard.
At 10am Bonner began complaining of severe abdominal pain but she was not physically examined until after 5.30pm, by which time her abdomen was swollen, indicating a perforation.
An urgent CT scan was ordered, but owing to the deterioration of her condition, Bonner was not fit enough to be transferred.
She was later transferred to the intensive care unit and suffered two cardiac arrests and multi organ failure, and later died.
A post mortem examination found that she died from sepsis as a result of a bowel perforation sustained during her hysterectomy.
An inquest at Birmingham and Solihull coroner’s court ruled that she would “likely have survived” if Bonner’s symptoms had been acted upon sooner.
Her family instructed medical negligence lawyers to investigate her standard of care under University Hospitals Birmingham NHS Foundation Trust.
The trust has now admitted that there were “missed opportunities” to identify the source of the sepsis.
A Patient Safety Incident Investigation Report also stated that a piece of surgical equipment used during the hysterectomy was “not approved” as part of the trust’s policies and that the communication between staff “was limited”.
‘Lessons to be learned’
Jason Large, Bonner’s partner, and her sons, Corey Wilson and Shakil Stevens, from Edgbaston, Birmingham, are now calling for “lessons to be learned” from the tragedy.
Mr Wilson said: “It’s almost impossible to find the words to describe the hurt we feel over mum’s death.
“When she went into hospital for surgery, we never thought she wouldn’t return home. Seeing her in those final days was terrible and we were so powerless to help.
He added: “The inquest and listening to the evidence as to why she died has been traumatic but it was something we were determined to do to at least honour her memory.
“I don’t think we’ll ever get over losing mum in the way we did.
“To hear the issues she faced in hospital has just added to that upset, particularly finding out that it’s likely she would have survived if her injury had been found sooner.”
Since her death, a number of recommendations have been made in the NHS Trust’s Patient Safety Incident Investigation Report.
These include a review of the Good Hope Hospital theatre procedures to identify equipment that needs replacing, as well as an audit to ensure all abnormal observations proceed to a higher frequency, such as hourly observations.
Joe Matchett, the specialist medical negligence lawyer at Irwin Mitchell representing Jessica’s family, said: “This is a truly tragic case which has left Jessica’s family heartbroken.
He added: “Sadly, the inquest heard worrying evidence not only regarding the care Jessica received but also regarding communication between medical staff and the use of unapproved surgical equipment.
“While nothing can make up for Jessica’s death, we’re pleased that we’ve at least been able to provide her family with the answers they deserve.
“Jessica’s death is a stark reminder of the dangers of sepsis and how early detection and treatment are key to recovery.
“It’s now vital that lessons are learned from the issues identified by the Hospital Trust in its own internal investigation and the inquest to improve patient safety.”
A spokesman for the University Hospitals Birmingham NHS Foundation Trust said: “We extend our deepest sympathies and a heartfelt apology to the family of Jessica Bonner.
“Jessica should have received a much greater level of care from our Trust.
“We are committed to learning, and we will continue to work to improve the care and safety of our services, so that no other family endures the pain that Jessica’s loved ones now face.”
Source Agencies
