Video report by Rachel Townsend
A lack of basic medical care and knowledge from health professionals contributed to the death of a Blackpool woman following an abortion, according to the family's lawyer.
'Devoted' mother of five Sarah Dunn, 31, died on 11 April last year - less than three weeks after her planned termination.
In that time, she spoke to her GP, the surgery pharmacist and the out of hours doctor several times about worsening symptoms; in one instance saying she had "never felt so poorly", and in another that she was "unable to move".
At this point - 19 days on from the procedure - she was rushed to Blackpool Victoria Hospital where she suffered a seizure and multi-organ failure, later identified to be as a result of sepsis which had been missed.
'Despite all efforts', Sarah had a cardiac arrest at 12:50am, with her death recorded eight minutes later.
At the end of a five-day hearing into the circumstances last month, coroner for Blackpool Louise Rae found Sarah had died of natural causes contributed to by neglect.
She found "gross failings" in her hospital care and "basic failings" from her GP and pharmacist.
Those 'delays' were attributed to the outbreak of the coronavirus pandemic and the subsequent lockdown.
While this presented certain challenges, the coroner has called for a better understanding of maternal sepsis.
Dr Grahame Goode, the Deputy Medical Director of the Blackpool Teaching Hospitals NHS Foundation Trust, 9 November released the following statement:
"I can only imagine the pain that Sarah’s family have been through after losing her in these terrible circumstances. It’s difficult for anyone to comprehend the impact that losing their mother will have on her children and family.
“Blackpool Teaching Hospitals has been present to hear all the evidence during the inquest and we fully accept all the findings of the coroner, and offer our heartfelt condolences to Sarah’s family.
“There are clearly things that could have been done differently during the time we were caring for Sarah that have been highlighted, and while they may not ultimately have saved her life, could have played their part.
“I would like to apologise to Sarah’s family on behalf of the Trust and I can reassure everyone that the circumstances around her death have been investigated fully."
The Healthcare Safety Investigation Branch has published its independent report into the case, including nine recommendations:
The unplanned pregnancy service should ensure that the aftercare leaflet explicitly states that if a woman is concerned about signs of infection, she should contact the unplanned pregnancy service, using the 24 hour helpline.
The GP practice should ensure that all clinical staff are aware of and supported to provide clinical care in line with best practice for post abortion care.
The GP practice should ensure that different sepsis screening tools are available and the relevant tool is used according to the presenting clinical circumstances.
The GP practice should ensure that all clinical staff are aware of and are supported to recognise and act on signs of infection and/or sepsis.
The out of hours GP service should ensure that all clinical staff are aware of and supported to recognise and act on signs of infection and/or sepsis, prompting referral to hospital where indicated.
The GP practice should develop, embed and monitor policies and processes to ensure allied healthcare clinicians involved in advanced clinical practice are fully supported to work within their agreed boundaries of clinical practice.
The GP practice should ensure that a robust structured framework is in place to ensure clinical supervision is provided to clinicians in training.
The GP practice should ensure there is a robust triage and associated pathways in place to enable patients to be reviewed by a suitably trained and experienced healthcare professional.
The Trust should ensure staff complete a full and holistic assessment, in order to rule out other possible clinical conditions and enable the correct management plan and treatment.