Inquest finds hospital staff “neglect” a factor in death of woman with bowel obstruction

A 25-year-old woman died at her parents’ home after hospital staff failed to spot the bowel obstruction that killed her on an X-ray.

Juliet Saunders was admitted to King George Hospital, Ilford, on March 7 last year with abdominal pains and vomiting but was discharged after being wrongly diagnosed with gastritis and died on March 9.

An inquest at Walthamstow Coroners’ Court held on April 30 heard the doctor who saw Ms Saunders displayed a “lack of clinical curiosity” and should have escalated her to a more senior doctor.

Ms Saunders suffered from a rare genetic condition, Cornelia De Lange syndrome, that made her more vulnerable to bowel problems. She was also severely learning disabled and “largely non-verbal”.

Her parents saw she seemed to be in abdominal pain and vomited “a thick, deep yellow substance” on March 7. They called 111, who requested an ambulance to take her to hospital.

Summarising the evidence he heard during the inquest, coroner Graeme Irvine said: “I have been reminded that March 2020 was the very start of the pandemic and that the emergency services were under some strain.

“The registrar in the emergency department at the time was unfamiliar with the syndrome. She was a relatively junior doctor but, when presented with a patient with a highly unusual and complex history, did not transfer responsibility to the ward’s consultant.

“She arrived at a query diagnosis of gastritis and pursued this diagnosis, even when further evidence in the form of lab tests cast doubt upon its credibility.

“She said she spoke to her supervising consultant… and that he agreed with her proposed course of action but, in the absence of any evidence, I have to treat her account with some level of scepticism.

“Fundamentally, this inquest has been hamstrung to some degree by the lack of contemporaneous records. (The registrar’s) notekeeping was limited to a single entry.”

The lack of notes also meant there was “no clear evidence” presented to the inquest that the doctor actually looked at the X-ray taken of Ms Saunders, although she told the court that she did.

Then-head consultant Dr Akin Idowu told the court there were three “clear signs” of an obstruction on this X-ray, missed by the doctor and later by one of the trust’s radiographers.

Ms Saunders was transferred in the afternoon to another unit for observations with “no evidence of clinical input”, despite the hospital’s policy stating a consultant should have signed off it.

The observations unit did not make any notes on Ms Saunders and later discharged her without any examination or review from a clinician.

Mr Irvine noted that Barking, Havering and Redbridge University Hospitals NHS Trust, which runs Queens, accepted there were “failures in care” but argued they could not be considered “gross” failures because Ms Saunders was such a complex patient.

Mr Irvine rejected this argument, adding: “The trust’s failures led to Juliet not being admitted to hospital. Had she been admitted for active monitoring, there would probably have been an opportunity… to save her life.

“The trust allowed Juliet and her family to leave hospital without… advice on what to do if she deteriorated and it seems to me this must be the most cruel aspect of the case. I feel sure they would have taken those steps admirably.”

He added that he expected the trust to refer the registrar involved in Ms Saunders’ care to the General Medical Council and would so himself if it failed to do so.

He concluded the inquest with the finding that Juliet died of “natural causes, contributed to by neglect”.

  • An earlier version of this story supplied by the Local Democracy Reporting Service erroneously stated that the hospital involved was Queen’s at Romford. This has now been corrected

Victoria Munro

Local Democracy Reporter