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Inquest: "Indefensible" Decisions Led to Sepsis Death
3 Oct
Summary
- Hospital decisions directly contributed to a young woman's sepsis death.
- A&E information indicating internal perforation was not acted upon quickly.
- Coroner reported two doctors to the General Medical Council.
Failures at West Suffolk Hospital "directly contributed" to the death of 28-year-old Hannah West from sepsis, an inquest has found. The coroner's hearing revealed that critical information about Ms West's condition was not acted upon swiftly enough.
Ms West arrived at the hospital in Bury St Edmunds on January 18, 2024, shortly before 1 AM, with two self-inflicted abdominal wounds. She informed staff that the object piercing her skin had gone in clean but come out dirty, suggesting a possible internal perforation.
However, this crucial detail was reportedly not acted upon quickly or passed to the on-call surgical consultant. Instead, a "conservative" care plan involving observations and antibiotics was initiated. Ms West's condition deteriorated over seven hours before surgery was prepared, and eventually performed, more than ten hours after her initial arrival.
An expert witness described the decision to opt for conservative care over urgent surgery as "utterly indefensible." Following the hearing, the coroner took the rare step of reporting two doctors involved in Ms West's care to the General Medical Council.
