A MUM died from sepsis after medics used equipment “not approved” by the NHS to carry out a hysterectomy.
Jessica Bonner, 51, caught a flesh-eating bug after delays by doctors in diagnosing a perforated bowel.
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She would “likely have survived” if her symptoms had been acted upon sooner, an inquest has ruled.
Jessica was admitted to Good Hope Hospital in Birmingham last October after suffering pelvic pain.
The pain was caused by fibroids, the medical term for non-cancerous growths in or around the womb.
Mum-of-two Jessica underwent a hysterectomy and oophorectomy to remove her womb and ovaries.
But the next day Jessica developed a fever and her heart rate increased.
The day after that, a CT scan revealed a suspected perforated bowel which required emergency surgery.
By then, it was too late – Jessica’s condition continued to deteriorate and she died on October 8.
A post mortem examination found she died from sepsis as a result of a bowel perforation sustained during her hysterectomy.
An inquest at Birmingham and Solihull Coroner’s Court has ruled Jessica would “likely have survived” if medics had acted earlier.
Her family instructed lawyers to probe her standard of care under University Hospitals Birmingham NHS Foundation Trust.
The trust has now admitted there were “missed opportunities” to identify the source of the sepsis.
A patient safety report found a piece of surgical equipment used during the hysterectomy was “not approved” by the trust.
The report also said communication between staff treating Jessica was “limited”.
‘UNANSWERED QUESTIONS’
Jessica’s partner Jason Large and her sons Corey Wilson and Shakil Stevens are now calling on lessons to be learned from the tragedy.
Corey said: “It’s almost impossible to find the words to describe the hurt we feel over Mum’s death.
“When she went into hospital for surgery, we never thought she wouldn’t return home.
“Seeing her in those final days was terrible and we were so powerless to help.
“Trying to grieve for Mum while having so many unanswered questions has been incredibly difficult.
“The inquest and listening to the evidence as to why she died has been traumatic.
“But it was something we were determined to do to at least honour her memory.
“I don’t think we’ll ever get over losing Mum in the way we did. To hear the issues she faced in hospital has just added to that upset.
“Particularly finding out that it’s likely she would have survived if her injury had been found sooner.
“We’d do anything to have Jessica back in our lives but we know that’s not possible.
“We just hope that by speaking out we can help improve patient care for others.”
Corey added: “We wouldn’t wish what our family are going through on anyone.”
‘MISSED OPPORTUNITIES’
The inquest heard how Jessica recorded a high temperature and elevated heart rate after her surgery – both indicators of infection.
But the observations were not flagged to the ward consultant or surgeon.
At 10am, Jessica began complaining of severe abdominal pain – but she was not physically examined until 5.30pm.
By then, Jessica’s abdomen was swollen, indicating a bowel perforation.
An urgent CT scan was ordered, but due to deterioration of her condition, Jessica wasn’t fit enough be transferred.
Jessica was subsequently transferred to the hospital’s intensive care unit.
She suffered two cardiac arrests and multi organ failure and was pronounced dead.
Since Jessica’s death, a number of recommendations were made in the NHS Trust’s Patient Safety Incident Investigation Report.
These include a review to identify surgical equipment that needs replacing.
The report also suggests an audit to ensure medics closely monitor all abnormal observations.
‘DEVASTATING’
Lawyer Joe Matchett, representing Jessica’s family, said: “This is a truly tragic case which has left Jessica’s family heartbroken.
“Understandably, they’ve had a number of concerns about the care Jessica received and the events that unfolded in the lead up to her death.
“Through our work, we often see the devastating consequences that families can be left to face because of conditions such as a perforated bowel and sepsis.
“Sadly, the inquest heard worrying evidence not only regarding the care Jessica received but also regarding communication between medical staff and the use of unapproved surgical equipment.
“While nothing can make up for Jessica’s death, we’re pleased that we’ve at least been able to provide her family with the answers they deserve.
“Jessica’s death is a stark reminder of the dangers of sepsis and how early detection and treatment are key to recovery.
“It’s now vital that lessons are learned from the issues identified by the Hospital Trust in its own internal investigation and the inquest to improve patient safety.”
University Hospitals Birmingham NHS Foundation Trust said: “We extend our deepest sympathies and a heartfelt apology to the family of Jessica Bonner.
“Jessica should have received a much greater level of care from our Trust.
“We are committed to learning, and we will continue to work to improve the care and safety of our services, so that no other family endures the pain that Jessica’s loved ones now face.”
