An inquest into the death of a 25-year-old woman, who led a ‘fulfilling life, regardless of any disability’, has ruled that she died from hospital neglect.
Juliet Saunders was diagnosed with Cornelia de Lange Syndrome shortly after her birth. Features of the condition include short stature, hearing impairment, feeding and learning difficulties. Surgery performed at Great Ormond Street hospital, when she was less than three months old, enabled Juliet to grow up healthy and happy, enjoying a busy life at her day-centre, including horse-riding.
Juliet became ill during the night of Friday, 6 March, and was taken by ambulance the next day to the Accident and Emergency Department at King George Hospital, Ilford, where she was diagnosed with gastritis. Her parents had warned clinical staff that people with Cornelia de Lange Syndrome have an increased risk of bowel obstruction and were relieved to be reassured by the Registrar that this could be ruled out. Juliet was sent home after a few hours on 7 March without any further observations being carried out or guidance given.
Juliet died suddenly and unexpectedly at home in the early hours of Monday, 9 March. A subsequent post-mortem examination showed that she had died of a small bowel perforation as a result of volvulus and intestinal malrotation, or, in other words, an obstruction.
Prior to the Inquest, at the request of the Coroner, the Barking, Havering and Redbridge University Hospitals NHS Trust had produced a Serious Incident/Root Cause Analysis Report. The first version was criticised by the Coroner in November and the second version was also “flawed”. Juliet’s parents did not feel that all their questions had been fully answered nor were the issues addressed so as to learn from the mistakes made.
Her parents, Christine, and Francis Saunders instructed Solicitors at Hugh James to represent them at the inquest into her death, which was opened on Thursday 22 April 2021. Senior Associate, and Head of the Hugh James Inquest Team, Lynda Reynolds, appointed Barrister, Rose Harvey-Sullivan, of 7BR Chambers, to ask questions on behalf of the family into the care she received.
The Coroner heard evidence from Trust clinical staff and an expert witness instructed by the Court. This witness provided “significant” evidence: Juliet should have been admitted for observation on the basis of her medical history and that, had corrective surgery been attempted, on balance of probability, her life could have been saved. The Coroner concluded the inquest on 30 April 2021. He confirmed that Juliet had died of a small bowel perforation as a result of a volvulus and intestinal malrotation, the underlying cause of this was her Cornelia de Lange syndrome.
In his conclusions the Coroner listed 14 areas of concern in her care, these included:
- There was a failure to review the London Ambulance Service records upon admission.
- There was a failure to acquire adequate history from Mr & Mrs Saunders about Juliet’s illness and underlying condition.
- There was no access to the learning disability staff in A&E.
- The Registrar was relatively junior and there was no discussion with the consultant despite Juliet’s complex needs.
- Juliet had an increased blood lactate level and this was attributed to gastritis even when other blood tests would have cast doubt on this diagnosis, which was pursued in the face of the evidence.
- The x-rays taken of Juliet were incorrectly interpreted by the junior Registrar.
- On balance of probability the Registrar did not show the x-rays to the consultant.
- The Registrar concluded it was safe to discharge Juliet after completion of IV fluids.
- The record keeping fell below the standard of a reasonably competent doctor.
- The transfer of Juliet from A&E to the observation area was in contravention of the policy for a consultant review before this action can be taken.
- No observations were taken in the observation ward before discharge in contravention of the Trust’s policy.
- The radiographer who reviewed the x-rays after Juliet’s discharge did not diagnose the obstruction. Diagnostic overshadowing interfered in his identification of three key indicators.
- Juliet was discharged home without any advice or safety netting.
- Juliet was discharged home without additional observations or a repeat lactate blood test. She was not admitted to hospital, this was an opportunity to offer care which would “probably “have saved her life.
The Coroner confirmed that some of the above failings were such that the legal test for neglect in a Coroner’s conclusion was met. His conclusion was that her death was from natural causes contributed to by neglect.
The Coroner indicated that the Registrar should self-report to the GMC for consideration of her fitness to practice. He is also making a Prevention of Future Deaths Report to highlight his concerns to the Trust, CQC and Secretary of State for Health.
Of particular concern is that the Trust had prepared an SUI report, which had already been internally reviewed and amended yet despite this it still had not identified the failings that the Coroner had listed such as the unsafe discharge, nor had it addressed whether Juliet’s death was avoidable. While some steps had been taken to improve safety by the Trust there was still no plan to address the provision of staff for learning disabled patients and no referral had been made to the GMC to address the serious failings by the Registrar.
Commenting on the verdict, Christine Saunders, Juliet’s mother said:
"Juliet was the joy of our lives, our “precious pearl without a flaw”, who gave us, and all who knew her, so much happiness.
But she is no longer here: her voice has been stilled, owing to the flaws in her treatment and lack of a safety system to protect her. Real changes need to occur, or else we will not be the last family to suffer needlessly.
Our home is filled with memories of Juliet, but she is absent. No more will she throw her toys about, steal our keys, deliberately block the TV screen, and grasp us tightly in her little arms. Those cuddles were the best part of our day and we will miss them and her forever.
We would like to thank Miss Harvey-Sullivan for her steadfast support in this bewildering process, she has consistently tried to lighten our ordeal. We would like to express our gratitude to the Coroner, Mr Irvine, for his conduct of the inquest and, most of all, for the care he has taken throughout to emphasise that our daughter Juliet was a much-loved and happy young lady with a fulfilling life, regardless of any disability.”
Mr & Mrs Saunders, who paid tribute to their daughter last year in a moving Obituary for The Guardian, now want to focus on the life that Juliet lived and how much she is missed by those who loved her.
Head of the Hugh James Inquest team, Lynda Reynolds, added:
“This has been an extremely sad case, and the family are still heartbroken. Sadly, we see too many occurrences of adults with learning disabilities in clinical settings not getting the care they need. This inquest shines a light on how the system failed Juliet Saunders. I hope it serves as warning and a catalyst to effect a positive change in clinical care for those most vulnerable.”
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