All the failures that contributed to the death of UWE rugby player Maddy Lawrence
An inquest has heard that 20-year-old rugby player Maddy Lawrence would not have died had it not been for a number of failures in her care at Southmead Hospital in Bristol.
The University of the West of England student suffered a dislocated hip during a match on 9 March 2022 and was admitted to hospital.
Over the following days, her condition deteriorated, but staff failed to acknowledge how seriously unwell she had become despite Maddy being in significant pain.
She died on 25 March with a bacterial infection after having her leg amputated.
Coroner Dr Peter Harrowing said 'gross failures' in her care had contributed to her death and that a number of opportunities were missed.
During the hearing at Avon Coroner's Court, he summed up the failings at Southmead Hospital as follows:
Failure by nursing staff to undertake and record observations and National Early Warning Scores (NEWS), a tool which is used to improves the detection of deteriorating conditions in adult patients
Failure to act appropriately on NEWS
Failure to do sepsis screening at NEWS score 5, a score that should have prompted an urgent review by a clinician
Failure to seek a timely medical review
Failure to follow acute kidney guidelines
Failure to acknowledge how seriously unwell Maddy was
During the inquest, Maddy's cause of death was given as 'multi-organ failure, strep A, sepsis (necrotising myositis)'.
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.
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 coroner told the inquest that on that day South Western Ambulance Service was facing unprecedented demand.
He said he was satisfied Maddy was given the appropriate level of response on that day, that it was escalated and that staff acted appropriately.
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.”