An inquest into the death of 20-year old woman has found that multiple failures by the University Hospitals Plymouth NHS Trust following a routine appendicectomy led to her premature death from sepsis and multi-organ failure.
Chloe Rideout was admitted to Derriford Hospital on 7 October 2018 with acute abdominal pain. Two days later, she underwent surgery to remove her appendix. She was then prescribed antibiotics, as advised by microbiology, but had a slow post-operative recovery.
In response to this, blood tests were taken on prior to her discharge on 13 October 2018. However, the results were not checked by the medical staff before Chloe was discharged, despite them showing abnormalities. Additional errors were also made by the medical staff with the prescription for her discharge medication, with a failure to prescribe two of Chloe’s antibiotics. She was discharged by doctors who were not familiar with her, and who failed to recongise she had deteriorated clinically.
On her discharge, Chloe continued to suffer from abdominal pain and felt unwell, leading her mum, Sharon, to contact 111 services. An Advanced Nurse Practitioner did a home visit and reviewed Chloe’s anti-sickness medication and painkillers, while also providing a laxative. However, Sharon remained concerned and called 999 within 10 minutes of the nurse leaving. Chloe was taken by ambulance to the Emergency Department at Royal Cornwall Hospital. Peritonitis and sepsis were thought to be the likely diagnoses and Chloe was admitted.
Chloe’s liver function tests, which had been abnormal on her discharge, deteriorated further and she began treatment for liver failure. Advice was sought from King’s College Hospital, London and further abdominal surgery was performed on 17 October 2018, during which time Chloe also started treatment for kidney failure. More abdominal surgery was required, but Chloe continued to deteriorate, suffering from multi-organ failure. This affected her brain, and testing confirmed brain stem death. She died on 20 October 2018.
The inquest took place between the 12-14 May, heard remotely via videolink. The Coroner was Acting Senior Coroner for Cornwall and the Isles of Scilly, Mr Andrew Cox.
The Coroner instructed two expert witnesses, surgical expert Professor Winslet and hepatology expert Dr Mervyn Davies. The inquest heard evidence from Chloe’s Consultant Surgeon about the lack of continuity of junior doctor support, which contributed to the errors in care that were made. The inquest concluded that, had Chloe’s clinical deterioration been recognised and had her blood results been checked she would have remained in hospital, her correct antibiotic prescription would have continued, and she would not have died.
Chloe’s mum, Sharon described her daughter as a ‘lovely person, who gave so much to other people’. Sharon emphasised that Chloe was fit and well prior to her initial operation.
“She had run six miles, just two days before she fell ill. Chloe was a strong, fit 20-year-old woman, who had gone into hospital for a routine operation and died. We, as a family, cannot believe that so many professionals did not spot any signs of sepsis and we feel that so many people have let Chloe down. You worry about your children driving, going out at night, and drinking alcohol but not at any stage do you think you need to worry about your child having a routine operation in hospital.
“Chloe’s death has affected so many lives. As parents we have been robbed of our daughter. It has completely wrecked the lives of me, her dad and her brother. It has affected the lives of her relatives and many friends.
“As Chloe’ s parents we are very concerned about the care that Chloe received. Chloe was a young lady with her life ahead of her and it has been ripped away from her. We want to make sure any failings by the healthcare providers are fully investigated and we want to prevent happening to anyone else.”
Dawn said: “The failings of the doctors involved in Chloe’s care were very basic errors which should not, under any circumstances, have happened. With the correct treatment, Chloe would not have died. Chloe’s suffering prior to her death was horrendous for both her and her family. A young life full of promise has needlessly been lost. The Coroner’s finding of neglect is entirely appropriate in this case. It is imperative that the Trust make changes to reduce the likelihood of such errors happening again, and it is reassuring that steps have already been taken in this regard.”
Deputy Medical Director for University Hospital Plymouth, Paul McArdle, apologised to the family after the Trust’s evidence was heard. He apologised unreservedly for ‘missed opportunities in care that might have led to a different outcome’
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