‘Gross failures’ in hospital contributed to death of Bristol rugby student

An inquest has found that a series of “gross failures” in a student’s care while in hospital contributed to her death.

Maddy Lawrence died from an infection in Southmead Hospital on March 25, 2022 after dislocating her hip at a rugby match a fortnight earlier.

A coroner found that doctors and nurses missed a “number of opportunities” to prevent the 20 year old’s death.

He added that as her “condition deteriorated”, doctors “failed to recognise how unwell Maddy was” and key antibiotics were not administered which could have saved her life.

North Bristol NHS Trust chief medical officer, Tim Whittlestone, apologised on behalf of the Trust for “omissions in her care”

The coroner, Dr Peter Harrowing, said the UWE student was a keen rugby player whose tutors thought “extremely high of”.

Maddy Lawrence played on the wing for UWE Women’s Rugby – photo: UWE Women’s Rugby

He said Maddy was a fit, healthy, young woman when she died but had the remains of a tonsillitis infection which she had taken antibiotics for when she went into hospital.

The coroner concluded that the remains of the infection had entered her bloodstream and attacked her body tissue, likely leading to sepsis or toxic shock syndrome, and died in intensive care.

A system called News, a national early warning score, was used by the hospital to monitor her condition.

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Read more: ‘Maddy presence, bravery, spirit, goodness, sass, beauty and love will never be forgotten’

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An expert said Maddy could have survived if she had been given antibiotics earlier, but at one point, doctors and nurses did not record observations about Maddy on the news system for 16 hours.

Reading his verdict, Harrowing said there had been “a number of failures in Maddy’s care while at Southmead Hospital”.

“Failure by nursing staff on a number of occasions to undertake observations, failure to act appropriately on the news score on 4 and 5, failure to undertake sepsis screen when news score high, failure to seek a timely senior medical review, failure to follow acute kidney injury guidelines, and failure to recognise how seriously unwell Maddy was.”

He concluded that there were “a number of opportunities to render care which would have meant Maddy could not have died when she did.”

Harrowing praised the “heroic efforts” of Maddy’s physiotherapist, Mr Tonkins, on the rugby pitch, who looked after Maddy for a “number of hours” with “limited resources.”

He also ruled out neglect on behalf of the ambulance service, who had been facing “unprecedented demand” on the day, at one point, having only one ambulance available for Maddy’s area.

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.

NHS staff will now have mandatory training on the news system that indicates signs of sepsis and other serious infections, following Maddy’s inquest – photo: Mia Vines Booth

“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.”

Following the inquest into Maddy’s death, staff will have mandatory training on the news system that indicates signs of sepsis and other serious infections, a senior trust employee told the inquest.

Main photo: UWE Women’s Rugby

Read next:

• Tributes paid to UWE student, Maddy Lawrence, who died following injury
• Parliament to debate how better to help protect university students
• UWE Bristol student helps combat food poverty

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