Valerie Pierce, a mother of two, died on 30 March 2015, aged 45, at Weston General Hospital after succumbing to infection. The Assistant Coroner for Avon investigated her death and gave a narrative verdict.

Treatment at Weston General Hospital

Valerie had suffered from abdominal pain for a number of years and had attended both her GP and the hospital on a number of occasions.

Valerie's symptoms persisted and she was admitted to Weston General Hospital as an emergency on 27 February 2015. She was diagnosed as having Crohn's disease and treated with steroids and antibiotics. Tests revealed that Valerie had a stricture in her small bowel, caused by her Crohn's disease. She remained an inpatient at the hospital and surgery was planned for 18 March.

Diagnosis of sepsis

In the early hours of the morning of 15 March, Valerie suffered a perforation to her small bowel and was clearly suffering with severe pain, dangerously low blood pressure and signs which indicated a rapidly developing sepsis infection. At that time there were only two doctors, both juniors, responsible for the entire hospital. The junior doctor administered treatment in the form of antibiotics and intravenous fluids but Valerie's condition continued to deteriorate.

Mr Chandratreya, the on-call senior consultant surgeon, was contacted at home but decided that it was not necessary for him attend the hospital to carry out emergency surgery, unless Valerie's condition became worse, until his shift started later that morning. When asked by the junior doctor at the hospital if she should prepare the surgical team, Mr Chandratreya said not to. Valerie's condition deteriorated further and the junior doctor contacted the consultant surgeon for a second time. Again, he declined to operate and said that he would perform the urgent surgery when he attended later that morning.

There was a period of delay before the surgery took place. By the time Valerie came to surgery at about 9.30am that morning after an assessment, and after the operating theatre had been prepared for surgery, she was in a state of 'peri-arrest' and required an injection of adrenalin to stabilise her. When the procedure eventually took place, the surgeon found significant faecal contamination in Valerie's abdominal cavity.

Over the following two weeks, Valerie underwent a number of further procedures to manage the infection in her bowel, culminating in a procedure to reset the surgical bag used to remove waste matter from her body. During this procedure, Valerie suffered a cardiac arrest and sadly died.

The Coroner found that she died of pneumonia as a result of the bowel perforation, as well as an abdominal infection and fungal sepsis.

Coroner's investigation

Giving a narrative verdict, the Coroner said he was concerned that surgery had not taken place earlier. He identified a number of criticisms of the hospital but praised the junior doctors who had raised the alarm about Valerie's condition and initiated treatment for suspected sepsis. The Trust's Medical Director, Dr Nicholas Lyons, gave evidence at the Inquest and said that treatment protocols had been disseminated to ensure that lessons had been learned.

Sepsis treatment

The Trust had an 'acute abdominal pathway' in place which specifically highlighted the importance of sepsis monitoring and treatment. The document lists the 'Sepsis Six', a set of key treatments to be administered to a patient suffering from the condition. These include giving broad-spectrum antibiotics, oxygen supplementation and taking regular blood cultures.

When asked whether the acute abdominal pathway had been brought to the attention of the treating staff at the time of the incident, the junior doctor told the Inquest that it had not; this prompted a member of Trust management to concede that there needed to be greater transparency and communication of existing protocols at the hospital.

The family's lawyer, Laurence Vick, says:

'Sepsis claims the lives of nearly 40,000 people a year in the UK – clearly, this is a condition of serious importance in a hospital setting and there are extensive national and Trust level guidelines aimed at minimising the harm suffered by patients.

'If these guidelines are adhered to, the chances of a recovery are dramatically improved. Valerie's family need to know whether these guidelines were followed and could have saved her life.'

'One of the points to arise from the Coroner's investigation is the incredible pressures under which junior doctors are placed. Lack of resources does not justify inappropriate treatment and we need to know that staff in NHS hospitals, who are often absolutely excellent, are being given the support they require to provide safe care.

'The Coroner did not call expert medical witnesses to comment on the case and therefore felt unable to say whether, if Valerie's treatment had been different, she would have survived. We continue to investigate the circumstances around her death to find the answers the family seek.'