Inquest blast at NHS for failing to save girl’s life

Laura Garner’s mother broke down and wept yesterday as an inquest heard Bradford Royal Infirmary missed chances to diagnose the 18-year-old’s illness.

The trainee beautician died as a result of acute pyelonephritis – a serious bacterial infection of the kidney – and septicaemia, a post-mortem revealed.

Laura, of Baildon, West Yorkshire, was admitted at around 11pm on September 22, 2009, with excruciating back and abdominal pains, a fever and an abnormally fast heart rate. The next afternoon she underwent a laparoscopy, which ruled out appendicitis but failed to provide a diagnosis.

Later that night her condition deteriorated and she died just after midnight on September 24 after suffering a cardiac arrest.

The inquest was told basic observations such as temperature, pulse and blood pressure checks should have been carried out hourly, but one gap between them had been 11 hours.

An independent expert told the hearing at Bradford Coroner’s Court that Laura’s deterioration would have been recognised earlier if observations had been carried out “regularly and diligently”.

Professor Michael McMahon, a consultant surgeon with 30 years’ experience, said: “If the diagnosis had been made before the collapse, then a combination of antibiotic therapy and physiological support given, she should have achieved survival.”

He said Laura’s young age and otherwise good health gave a low chance of mortality and concluded there had been “a missed opportunity” to save her.

Prof McMahon added that the case “classically exemplified” a widespread NHS failure where taking observations had become a “Cinderella task” carried out by care assistants instead of nurses.

Coroner Paul Marks recorded a narrative verdict and used his powers to recommend the hospital’s observation policies are improved.

He said after her laparoscopy, no observations were carried out until 9.30pm on September 23, by which point her blood pressure was unrecordable.

“Such observations, if made, are likely to have shown evidence of deterioration and, if acted upon, may have permitted therapeutic intervention which evidence shows could have saved her life,” he said.

Speaking after the three-day inquest, Laura’s mother Anne Garner said: “Hearing the expert evidence that said my daughter would still be with us today if they had done their job and checked her was the hardest part.”

She had earlier told the inquest the hospital would not let her stay with her distressed daughter as she was classed as an adult.

“She was just a bairn – only just 18. I had to battle with them constantly to let me stay with her,” she said.

“She was a wonderful girl, a typical 18-year-old who lived every minute of her life and didn’t miss a minute of it.”

A spokesman for Bradford Teaching Hospitals NHS Foundation Trust said lessons would be learned from the tragedy.

“We would like to reiterate our sincere condolences to Laura’s family,” he said.

The spokesman added: “The trust has taken Laura’s death extremely seriously and we acknowledge care fell below an acceptable standard for which we apologise unreservedly.”