A UK hospital trust has admitted sepsis care and treatment failings after a previously healthy teenage mother died 48 hours after giving birth to twins, The Guardian reports. Sophie Burgess safely delivered a boy and a girl eight weeks premature, but never got to be with her children after falling seriously ill with sepsis and HELLP syndrome, a life-threatening pregnancy condition.
The report says the 19-year-old care worker’s family launched legal action against the trust that runs New Cross Hospital in Wolverhampton, following her death on 13 March 2015. Solicitors Lanyon Bowdler, acting for the family against the Royal Wolverhampton NHS hospital trust, said her death had been avoidable. Despite being diagnosed with sepsis at 9.50pm, Burgess was not transferred to an intensive care unit (ICU) for more than three hours, the law firm said.
The report says now, the trust has made admissions and said it regretted the circumstances which led to the young woman’s death. It added lessons had been learned “to identify and manage sepsis as early as possible”.
Kay Kelly, the clinical negligence lawyer representing the family, said: “She was just a 19-year-old, young, fit and healthy woman. After being instructed, we carried out an investigation which revealed extremely poor care on many levels which could and should have been avoided.
“Three reputable medical experts concluded that, if given proper care, if she had been taken to ICU, given fluids and been monitored and supported in intensive care, then Sophie would have probably survived to live a normal life, because she was strong.”
According to the report, she added: “She developed sepsis – a real concern in this country at the moment, because we’re not getting on top of it. She also had a nasty condition called HELLP, which is like pre-eclampsia. But in my view, she had clear symptoms of sepsis.
“What was really worrying is that no consultant took responsibility for her care, so there was really poor management. She should have had four different areas of expertise looking at her case.
“She should have had an obstetrician, an intensivist, a haematologist and an anaesthetist – the anaesthetist was allowed to go home in the middle of this incident.
“I think staff were busy and nobody senior recognised the seriousness of her condition.”
After going into labour, Burgess, from Telford in Shropshire, was initially transferred from her local hospital to New Cross because of a shortage of neonatal beds.
At New Cross she had the twins, Evie and Oliver, and, although premature, the births went smoothly. She was then taken to the recovery room and initially seemed fine, the family’s lawyer was quoted in the report as saying. “But then her temperature rose, her pulse increased, and they became concerned about her, that she possibly had a developing infection, gave her antibiotics.
“Her blood pressure went up and she just became very ill. So she never had a chance to see the twins. Her mother went to see the twins and brought a photo of them back to her daughter, which is really sad. The twins’ father stayed with her the entire time and was with her during this awful period.”
Midwives made repeated attempts to call for senior clinicians to attend to Burgess, but “nobody took important decisions and recognised how ill she was”, added Kelly.
The report says Burgess had been diagnosed with sepsis at 9.50pm, but a decision to have her transferred to intensive care came more than three hours later. She did not actually arrive in intensive care until 2.30am by which time she was in severe shock, Kelly said, adding that record-keeping had been “poor”.
“Sophie should have been reviewed and transferred by 10.30pm but instead she just had a midwife looking after her,” said the lawyer. “Even then, in ICU, there was a delay in giving her intravenous fluid and antibiotics – in giving her the urgent treatment she required – so she went into peri-arrest.”
The trust’s medical director, Jonathan Odum, is quoted in the report as saying: “The trust would once again like to offer our condolences and regret for the circumstances which led to the death of Sophie following the birth of the twins. The lessons identified from our investigation have been shared within the trust and continue to help us to identify and manage sepsis as early as possible.”The Guardian