Hairdresser died from kidney infection as hospital fail to observe her properly
London – A coroner has ruled a 18-year-old hairdresser needlessly died from a kidney infection because a blundering hospital failed to observe her properly.
Laura Garner was admitted to Bradford Royal Infirmary on 22 September 2009 suffering suspected appendicitis.
The teenager, who was otherwise fit and healthy, died a little more than 24 hours later after staff failed to carry out checks on her for up to 11 hours at a time.
A post-mortem revealed she died as a result of septicaemia and acute pyelonephritis – a serious bacterial infection of the kidney – but a three-day inquest into her death revealed missed chances to diagnose her.
An independent expert said if observations had been carried out regularly and diligently by staff at Bradford Royal Infirmary, Laura’s tragically young life could have been saved.
And he also told the hearing the problem with observations exemplified a
widespread failure in the NHS.
Coroner Prof Paul Marks, recording a narrative verdict at Bradford Coroner’s Court today said that despite Laura, of Baildon, West Yorks., undergoing a serious procedure to determine whether or not she was suffering from appendicitis, regular observations were not carried out, with one gap between observations being around 11 hours.
Prof Marks said: ‘There were no basic observations carried out on her until 9.30pm on September 23 at which point her blood pressure was unrecordable.
‘Such observations, if made, are likely to have shown evidence of deterioration and if acted upon may have permitted therapeutic intervention which evidence shows could have saved her life.’
Speaking after the inquest, Laura’s mother Anne Garner, who indicated the family would be pursuing a civil claim against the Trust, said: ‘Hearing the expert evidence that said my daughter would still be with us today if they had done their job and checked her was the hardest part.
‘I do not want anybody else to go through what we have gone through. That’s why we wanted this inquest, to make sure no other family has to go through this.’
The inquest heard Laura died just after midnight on September 24 after
suffering a cardiac arrest. Her mother had sent Laura a text at 11.45pm to say she loved her, but did not get a reply. A phone call from the hospital came shortly after 1am to say Laura had died.
The coroner heard evidence from Professor Michael McMahon, a consultant surgeon with 30 years’ experience.
He told the hearing that there had been a ‘systems’ failure in Laura’s case and said the incident exemplified a failure in the NHS as a whole.
He told the court: ‘On the balance of probability, had her observations been carried out regularly and diligently then her impending problem would have been recognised earlier.
‘If the diagnosis had been made before the collapse then a combination of antibiotic therapy and, in the first instance, physiological support given, she should have achieved survival.
‘There was a low chance of mortality on the basis of the fact she was a young woman and otherwise fit. The likelihood of survival was more than 51 per cent.
‘I would have to say on the balance of probability there was a missed opportunity.’
Prof McMahon told the inquest that Laura’s was an especially ferocious case of pyelonephritis, especially in an otherwise well young girl, and in this case the septicaemia had overwhelmed her.
He said: ‘This was not only a tragic case but an unusual case and most of the staff who saw her would not have seen such a severe attack of acute pyelonephritis as that suffered by Laura. It is not a diagnosis that immediately comes to mind.’
Mrs Garner also gave evidence to the hearing, saying she had repeatedly asked hospital staff to be allowed to stay with her distressed daughter, but this was refused as Laura was classed as an adult.
Speaking after the case, she said: ‘She was just a bairn – only just 18. I had to battle with them constantly to let me stay with her.
‘She was a wonderful young girl, a typical 18-year-old who lived every minute of her life and didn’t miss a minute of it. It doesn’t get any easier – I was hoping the inquest would help even a little bit but I don’t think anything will.’
Laura’s father Steve added: ‘I still visit her everyday and will continue to.
She was such a popular girl, there were over 300 friends at her funeral and they still all go along to visit her.’
Bradford Teaching Hospitals NHS Foundation Trust prepared a serious incident report following Laura’s death which concluded that there were ‘deficiencies in the basic medical processes of differential diagnosis, investigation and treatment’.
Mrs Garner added: ‘They have been very frank and open with us from the start but these rule 43 directions mean they have to do what is being asked of them.
‘I just hope that prevents any family going through what we have been through. I can’t believe the way she has been treated.’ – The Daily Mail UK