Maddy Lawrence inquest: Student's death 'contributed to by neglect'

The inquest into the death of a student rugby player concluded that her death was contributed to by neglect.

Maddy Lawrence, 20, died from an infection at Southmead Hospital in March 2022, a fortnight after dislocating her hip during a match.

A coroner found her deterioration was "not recognised" and life-saving treatment "not commenced promptly".

North Bristol NHS Trust Chief Medical Officer Tim Whittlestone acknowledged "the omissions in her care".

Maddy developed an infection which likely led to sepsis or toxic shock syndrome, and destruction of body tissue, and died in intensive care.

The University of the West of England (UWE) student could have survived if she had been given antibiotics earlier, one expert said.

A system was in place called News - a national early warning score - that should have indicated any deterioration or, for instance, sepsis, the inquest heard.

At one point, hospital staff did not record observations about Maddy's condition for 16 hours, the hearing was told.

Recording a narrative verdict, Coroner Dr Peter Harrowing said there were "serious failings" in the care of Maddy, a student at the University of the West of England (UWE).

Karen Lawrence, Maddy's mum, said: "We are under no illusion as to where the burden should fall and who is responsible for failing to protect Maddy's life.

"Maddy herself expressed concerns that her pain was not taken seriously.

"We trusted the system. Her death was a result of a lack of care."

Mr Harrowing said: "There was a gross failure to provide adequate care.

"There were a number of opportunities to render the care to save Maddy's life.

"The investigation gives rise to concern of future deaths."

He added that there was a "failure to recognise how seriously ill she was".

Mr 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."

Staff will have mandatory training on a scoring system that indicates signs of sepsis and other serious infections, a senior trust employee told the inquest.

The coroner also heard how Maddy had to wait more than five hours for an ambulance to arrive after she was injured during the match on 9 March, 2022.

But Mr Harrowing said he did not find evidence for neglect by the South Western Ambulance Service NHS Foundation trust.

Its executive medical director Dr Matt Thomas said: "We would again like to offer our sincere condolences to the family and friends of Madeleine Lawrence. Our thoughts remain with them at what must still be a very difficult time.

"We are truly sorry that we were unable to provide the timely response that Maddy deserved.

"As documented during our evidence at the inquest, the service was under enormous pressure during this period, partly due to handover delays at emergency departments.

"We continue to work hard with our partners in the NHS and social care to do all we can to improve the service that patients receive."

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