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Student rugby player's death 'contributed to by hospital neglect'


The inquest into the death of a student rugby player has ruled that hospital neglect contributed to her death.

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

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

Maddy developed an infection, which is likely to have 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 even record observations about Maddy Lawrence’s condition for 16 hours, the inquest heard.

Recording a narrative verdict, Avon coroner, Dr Peter Harrowing, said there were "serious failings" in Maddy Lawrence’s care.

He 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. There was a failure to recognise how seriously ill she was."

North Bristol NHS Trust chief medical officer, Tim Whittlestone, said: "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."

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 Lawrence had to wait more than five hours for an ambulance to arrive after she was injured during the match.

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

The trust’s executive medical director, Dr Matt Thomas, said: "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."