The family of a student who died after hospital staff missed that she had developed sepsis despite a string of warning signs have claimed she was the victim of a “lack of care”, as a coroner ruled there were “gross” failures in her treatment.
Staff at Southmead hospital in Bristol failed to carry out the sepsis screening and observations needed to keep 20-year-old Maddy Lawrence safe after she was taken to hospital with a dislocated hip sustained in a rugby tackle.
Outside court, the student’s mother, Karen Lawrence, said: “It has been a constant struggle to understand how a healthy, strong and fit 20-year-old could lose her life to sepsis which was allowed to develop under the care of professionals.
“Her screams of pain and our pleas for help were merely managed, temporarily quietened with painkillers while the infection progressed unnoticed by hospital staff.
“Our daughter was failed by a number of nurses and medical staff; symptoms were ignored, observations were not taken, on one occasion for 16 hours. There was no curiosity, basic tests were not completed even when hospital policy required them.
“Maddy herself expressed concern on multiple occasions but her pain was not being taken seriously. As well as failing to fulfil their duty, those nurses and medical staff offered no sympathy, no compassion and little attention.
“This failure meant Maddy was not given the chance to beat sepsis. Significant delays in its discovery meant the crucial window for treatment was missed. Maddy did not die due to under-staffing or a lack of money. Her death was the result of a lack of care.”
The coroner, Peter Harrowing, said there were “gross” failures in her care. “Madeleine Lawrence died of a rare complication of an infection,” he said. “In hospital her deterioration was not recognised and necessary life-saving treatment was not commenced promptly.”
In the record of inquest, Harrowing said her death was “contributed to by neglect”.
The coroner’s conclusions come as UK ministers consider introducing Martha’s rule in England to make it easier for patients and their families who believe their concerns are not being taken seriously by staff to get a second medical opinion.
Martha Mills died aged 13 after developing sepsis while under the care of King’s College hospital NHS foundation trust in south London and a coroner ruled she would most probably have survived if doctors had identified the warning signs and transferred her to intensive care earlier.
Karen Lawrence praised the work of staff in the intensive care unit when her daughter was finally taken there. “Our heartfelt thanks go the ICU nurses who in the darkest of days found time to sit, to plait her hair and hold her hand and learn about familiar happy tales,” she said.
Lawrence sustained a dislocated hip when she was heavily tackled during a game for UWE Bristol on 9 March 2022. She lay in agony on the pitch for more than five hours while she waited for an ambulance, even though she was initially assessed as “category three”, meaning the average time for an ambulance to reach her should have been one hour.
The student’s father, Simon Lawrence, said his daughter was clearly unwell over the next few days, screaming out in pain and at times hallucinating.
She deteriorated rapidly, had a number of operations and one of her legs was amputated. On 25 March, family members were at her side when her respirator was switched off and, in her father’s words, she “faded away”.
The inquest was told that medical staff did not at first test her for sepsis and carry out regular observations, though her News (national early warning score) indicated this should have been done.
North Bristol NHS trust’s chief medical officer, Tim Whittlestone, apologised to Lawrence’s family.
He said: “Despite the rarity of Maddy’s condition and the heroic efforts of many of our clinical teams, we acknowledge and apologise for the omissions in her care. We will reflect carefully on the findings of the coroner.”
The coroner said the ambulance delay in getting Lawrence to hospital had not contributed to her death, adding that the service had been under “immense pressure” and said the player who tackled Lawrence should not reproach herself.