Coroner rules woman could have been saved from post-operative infections

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PROMPT medical intervention by staff at Northampton General Hospital may have saved a 23-year-old woman who died from post-operative infections, the county coroner has ruled.

Amy Page died from peritonitis and pneumonia in intensive care in the early hours of March 31, three days after undergoing abdominal surgery.

An inquest held in NGH’s boardroom yesterday heard Miss Page, formerly of Greenwood Road, St James, had been in severe pain following the operation on March 28. She had pressed a patient-controlled button to request pain relief more than 530 times during the short time she was in hospital.

But the hearing was told nursing and medical staff failed to contact senior staff to re-assess her condition – despite protocol under a monitoring system known as an “early warning score” suggesting they should – and had failed to spot signs of infection before her condition became critical.

Coroner Anne Pember, recording a narrative verdict, said there had been failures in Miss Page’s care, and a lack of escalation of her case to senior medical staff, despite her ongoing severe pain.

She said: “There was poor documentation in the nursing notes and also an absence of notes from doctors named here. There was a failure by medical and nursing staff to follow trust procedure for observations and escalation of early warning scores. At one time there was a gap of seven hours where an early warning score was not recorded.”

Mrs Pember concluded opportunities to treat Miss Page had been lost, adding: “Her rapid deterioration and untimely death may have been avoided with prompt medical intervention.”

Miss Page died at about 4am on March 31, after emergency exploratory post-operative surgery was unable to determine what was causing her deterioration.

Dr Jonny Wilkinson, consultant in intensive care and anaesthesia at NGH, commenting on a report into Miss Page’s case prepared by the hospital trust, said he was “unsure” if earlier intervention would have made a difference in her case, but he apologised on behalf of the trust for what had happened.

He said a new, clearer and easier-to-follow early warning score system was due to be adopted by the hospital with strict implementation guidance.

In a statement to the inquest Miss Page’s mother Joy said her family will never come to terms with her daughter’s suffering over the years and in the last few days of her life. She added: “I’m so proud of how Amy coped with her illness. She remained very strong throughout and rarely complained.”