'Gross failures' in Southmead Hospital care led to death of UWE rugby player Maddy Lawrence

An inquest has found "gross failures" in hospital care led to the death of 20-year-old rugby player and University of the West of England student Maddy Lawrence.

Coroner Dr Peter Harrowing said a number of opportunities were missed when she was taken to Southmead Hospital after suffering a dislocated hip during a match.

She was injured on 9 March last year and died two weeks later with a bacterial infection after having her leg amputated.

The inquest heard how staff at the hospital had failed to carry out a timely sepsis screening, and to acknowledge how seriously unwell Maddy was despite her being in severe pain.

Avon Coroner's Court heard had Maddy been given treatment for sepsis earlier, she would have survived.

The coroner said that on balance of probability the infection was treatable with antibiotics 48 hours before she had surgery on 14 March. She then underwent two further surgeries on 16 March to amputate her leg.

Dr Harrowing said nursing staff had also failed to undertake a record National Early Warning Scores (NEWS), a tool which is used to improves the detection of deteriorating conditions in adult patients.

He also said there had been a failure to act on NEWS scores, as well as failure to follow acute kidney guidelines.

Maddy Lawrence’s parents said her “presence, bravery, spirit, goodness, sass, beauty and love will never be forgotten”.

She was nick-named ‘twinkle toes’ by her rugby team where she played on the wing.

Her team described her as “bubbly and fun to be around” and videos show her leading her team in song on the bus after winning a match.

The club retired the number 11 shirt in her name.

Over seven days, the inquest heard how Ms Lawrence waited more than five hours for an ambulance.

Witnesses told the court that Maddy was tackled within the first few minutes of the friendly match, which kicked off at 3pm.

But she had to wait for an ambulance lying on the pitch "screaming" and "in massive pain" for several hours.

One witness said the ambulance did not arrive until around 8.30pm.

The inquest also heard how a bomb hoax led to her delays in receiving a hospital scan, that doctors had “a working diagnosis that was incorrect” and nurses missed observations.

When deputy chief nurse Dominique Duma was asked by KC Jonathan Jones, who was representing the family, what was her immediate reaction when she reviewed the case.

She said between tears: “I was really shocked, I was very cross. I was confused. I couldn’t understand it. It wasn’t the practice I recognised.”

Maddy's father told the court that Maddy felt she was being treated like a "difficult patient" and the nurses were not taking her pain seriously.

Mr Lawrence told the court that by 14 March - five days after the accident - his daughter was in a "huge amount of discomfort" and that staff were now taking the deterioration seriously.

Maddy was moved into the intensive care unit where her father said she was shouting and hallucinating. The decision was made to operate.

The following day her leg had to be amputated and Mr Lawrence said the family had "hoped she would recover". 

But early on 25 March, the family were told the final treatment had failed and her life support was switched off.

Following the conclusion of the inquest, North Bristol NHS Trust Chief Medical Officer, Tim Whittlestone, said: “Firstly, on behalf of the Trust I would like to say how deeply sorry we are to Maddy’s family, friends and teammates, and offer our unreserved, heartfelt apologies.

"As a parent, I can think of nothing worse than knowing there were missed opportunities which could have affected Maddy’s outcome.

"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.

"Beyond our apology we will reflect carefully on the findings of the coroner. The coroner noted the actions that we have already taken, and we recognise the improvements we still need to make.

"The recognition of, and our response to, deteriorating patients is the main safety improvement priority for our hospital.

"This includes enhancing training and the planned introduction of additional critical rapid response teams.

"Our thoughts and sincerest condolences remain with the family at this incredibly difficult time.”