Decisions before woman's sepsis death 'indefensible'

A woman who died in hospital after contracting sepsis could have survived if "indefensible" decisions had not been made, an inquest was told.

Coroner Darren Stewart concluded failures by West Suffolk Hospital "directly contributed" to the death of 28-year-old Hannah West.

At the end of Friday's hearing, he took the rarely seen step of reporting two doctors involved in her care to the General Medical Council, before recording a narrative conclusion.

Ms West died at the hospital in Bury St Edmunds having initially presented with self-inflicted wounds to the abdomen shortly before 01:00 GMT on 18 January 2024.

Notes from the Accident & Emergency department showed the patient was brought in by ambulance with two wounds to her stomach.

The item which pierced her skin had gone in clean and "come out dirty" she told A&E staff.

However, this information which indicated she may have an internal perforation, was not acted upon quickly enough or passed on to the on-call surgical consultant, the coroner was told.

Instead, "conservative" care was agreed which included observations, antibiotics and the administration of fluids.

Over the course of the next seven hours, Ms West's condition deteriorated but she was not prepared for surgery until 08:00 and it was not performed for another three and a half hours.

Expert witness Mr Omar Khan, a consultant general surgeon, told the inquest he believed it was "utterly indefensible" to proceed with conservative care instead of operating urgently.

Her inquest heard that nurses reported gastric fluid leakages to senior clinical staff and that a CT scan also showed the presence of fluid or gas in the abdomen, but that her surgery was not escalated.

Dr Khan said that "on the balance of probability" Hannah would have been likely to have survived if an emergency laparotomy had commenced by 08:00.

Surgery took place at 11:27, but by the time it was completed Hannah was already showing signs of septic shock.

She died the following day.

Senior surgeon Dr Akshay Bavikatte Prasannakumar made the decision for a CT scan rather than immediate surgery. That was despite another member of staff giving evidence to the inquest that they asked whether she should go to surgery immediately, because of the presence of faecal matter on the object which pierced Hannah's stomach.

Directly addressing the evidence of Dr Prasannakumar, coroner Darren Stewart said he gave the court "inaccuracies and half-truths intended to present a particular narrative that did not present him in the worst possible light".

He will be reported to the GMC by the coroner, along with one other doctor involved in Ms West's care.

In a statement read in court by the coroner Hannah's family described her as a woman who "loved with her whole heart".

"Hannah was a loving, kind, generous, forgiving and funny person," it said.

"Her mum, dad and brothers and sister loved her dearly and are devastated at her loss.

"She shaped the childhoods of every niece and nephew she had. Being an aunt wasn't just something she did — it was who she was."

The inquest also examined the care she received in the community for Emotionally Unstable Personality Disorder from the Norfolk and Suffolk NHS Foundation Trust.

Members of her family were in tears as the coroner detailed how she called 111 and an out-of-hours community care service because she "heard voices telling her to harm herself".

At one point, it was reported that she was told to "watch television" by the on-call mental health team when she was considering harming herself.

The coroner was told that her care plan had not been updated, nor had a safety plan. Her consultant psychiatrist was not present at multiple meetings regarding her care and treatment.

The family's solicitor Meg George said: "The coroner's conclusion leaves no doubt about the scale of multiple failures by West Suffolk NHS Foundation Trust and Norfolk & Suffolk NHS Foundation Trust [the county's mental health services provider].

"In relation to West Suffolk, the coroner found that these failures amounted to neglect and directly contributed to Hannah's death."

Dr Ewen Cameron, chief executive at West Suffolk NHS Foundation Trust, said: "I'm deeply sorry for the failures in our care for Hannah West. Our thoughts are with the family at this difficult time.

"Every single patient we see is deserving of safe, effective, and compassionate care, which are the foundational principles of the National Health Service.

"We regret the missed opportunities to operate on Hannah earlier. We accept the findings from the coroner and will continue to look at ways of improving the care we offer all our patients in the future.

"We've enhanced the training we undertake to aid decision making so these tragic events are never repeated."

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