"Neglect" by medical staff contributed to death of Bristol rugby player
Maddy Lawrence was killed by an infection developed at Southmead Hospital in Bristol
Last updated 11th Sep 2023
Neglect by medical staff at Southmead Hospital contributed to the death of a rugby player in Bristol.
That's what a coroner has concluded after a two week inquest into the death of Maddy Lawrence at Avon Coroners Court.
The 20-year-old passed away while being cared for at the North Bristol NHS Foundation Trust on 25 March 2022, a little over two weeks after being injured playing for UWE against the University of Bristol on 9 March.
Summing up the case today the coroner concluded there were a number of failings in Maddy's care meaning signs of her deteriorating condition were not acted upon when they should have been.
A "loving, warm and understanding" girl
At the start of proceedings, in a written statement prepared by her father, Maddy was described as "a wonderful daughter" who was "loving", "warm", and "understanding".
She was said to be very sporty, had set a school record for the 100 metres hurdles before going to university and was given a glowing reference by a former College teacher, who was quoted as saying "I have rarely taught students who light up the room as much as Maddy".
At the time of her death she was studying for an Interior Design and Architecture degree, where her lecturers were equally full of praise.
The injury
In written statements given by several of her teammates and friends, the inquest heard Maddy was injured a little more than five minutes into the match, which was a friendly against a team from the University of Bristol, at Lockleaze Sports Centre.
A physiotherapist who was present as an on site medic described her being tackled in a "big hit" after which she immediately began screaming in pain.
Such was the severity of the pain it was, the physio Paul Tomkins said, impossible to move her and so she remained lying on the pitch for around six hours until eventually an ambulance was able to take her to hospital.
Her treatment
During the course of proceedings the inquest heard three separate 999 calls were made that afternoon, from 3:24pm around 15 minutes after the injury occurred, to 5:50pm when physio Tomkins asked for the case to be escalated.
Several witness testimony's described how an ambulance eventually arrived at around 8pm and took her to hospital at around 9pm, by which time her teammates were taking part in a social by the pitch, as others including Tomkins kept her as comfortable as was possible.
Discussing her stay in hospital, Maddy's father described how she was initially in "good spirits", but that the next day she complained of more pain and said nurses had been "dismissive".
Following an operation to put her hip back in place, the inquest heard how she was due to have a CT scan to establish if the operation had been successful, but by the Monday (14 March) she had still not had one.
As her condition deteriorated she was eventually moved to Intensive Care and had her leg amputated in an attempt to save her, but on Friday 25 March doctors said the treatment had failed and advised her life support be turned off.
In a statement released following the conclusion of the inquest North Bristol NHS Trust Chief Medical Officer, Tim Whittlestone, said: “Firstly, on behalf of the Trust I would like to say how deeply sorry we are to Maddy’s family, friends and teammates, and offer our unreserved, heartfelt apologies.
"As a parent, I can think of nothing worse than knowing there were missed opportunities which could have affected Maddy’s outcome.
"Despite the rarity of Maddy’s condition and the heroic efforts of many of our clinical teams, we acknowledge, and apologise for, the omissions in her care.
"Beyond our apology we will reflect carefully on the findings of the coroner.
"The coroner noted the actions that we have already taken, and we recognise the improvements we still need to make.
"The recognition of, and our response to, deteriorating patients is the main safety improvement priority for our hospital.
"This includes enhancing training and the planned introduction of additional critical rapid response teams.
"Our thoughts and sincerest condolences remain with the family at this incredibly difficult time.”