Widower Joins Medical Negligence Experts At Irwin Mitchell In Calling For Lessons To Be Learned
The widower of a new mum who died as a result of sepsis just two weeks after undergoing an emergency caesarean has revealed his heartbreak over her death.
Kimberley Jeffries died aged 29 after delivering her first child, at Colchester General Hospital.
She was discharged two days after the birth but over the coming days sought hospital advice several times, with complaints of abdominal pain and bleeding. She was prescribed antibiotics for a possible womb infection.
Ten days after she was sent home, Kimberley, of Clacton, Essex, was readmitted by emergency ambulance to Colchester General in the early hours of 15 April, 2018.
Staff commenced treatment for sepsis but did not know the cause of her infection. It took staff more than two days to establish that it was “logical” that she had the womb infection endometritis which was suspected to be the source of her sepsis, a hospital investigation said.
With her condition deteriorating Kimberley was told she may need a hysterectomy to remove the infection – which she only had a 20 per cent chance of surviving, her family said.
She underwent emergency exploratory surgery during which pieces of placenta left over from her caesarean were removed.
However, doctors ruled she was too ill for them to continue with a hysterectomy to remove tissue killed by her infection, the source of which was never established.
Kimberley was transferred to surgery to undergo a hysterectomy. After hours of discussions among multiple doctors, medics believed this was her only slim chance of survival. However, Kimberley died on 18 April from multiple organ failure following a cardiac arrest.
Following her death, Kimberley’s family were concerned about the care provided to her. Kimberley’s husband, Christopher, 28, instructed expert medical negligence lawyers at Irwin Mitchell to investigate his wife’s care under East Suffolk and North Essex NHS Foundation Trust, which runs Colchester General, and support his family through the inquest process.
Christopher has now joined his legal team at Irwin Mitchell in calling for lessons to be learned after an internal investigation by the Hospital Trust found a number of issues over Kimberley’s care, including:
- A “failure” to recognise she could develop a number of potentially life-threatening conditions and “an apparent lack of knowledge” of their symptoms.
- There was a lack of a co-ordinated plan to care for Kimberley.
- Despite warning signs Kimberley was becoming unwell and despite the involvement of several senior staff there was a lack of appreciation of the potential for her condition to rapidly deteriorate
- The first “fully documented review” from a specialist maternity consultant took place more than 60 hours after her readmission
- There was “late recognition and subsequent suboptimal management” of her “rapidly deteriorating condition” from the evening of 15 April
- Note-keeping was “very patchy” which “made it difficult” to track Kimberley’s condition.
- “There was a lack of thoroughness” in examining Kimberley.
An inquest was told that the Trust had learnt lessons and had introduced a maternity services action plan covering areas including improvement of patient safety, communication and situational awareness through Maternity Safety huddles (MDT meetings), the use of MEWs scoring (early warning score) routinely in community midwifery to detect deterioration and sepsis and the use of electronic records in critical care. This record has improved tracking of progress and detection of deterioration.
Natalie Fox, specialist medical negligence lawyer at Irwin Mitchell representing Christopher, said: “This is a truly tragic case which understandably has left the family absolutely devastated.
“For many months Christopher and the rest of the family have had a number of concerns about what happened in the lead up to Kimberley’s death. The Hospital Trust’s internal investigation and the inquest have identified areas of real concern in the care that Kimberley received.
“We recognise that the Hospital Trust has identified a number of areas where patient care can be improved. It is now vital that these are implemented and enforced at all times to reduce the risk of others having to endure the pain that Christopher and the rest of the family are going through.
“We will continue to support Christopher at this incredibly difficult time and are working closely with the Trust to try and resolve the issues it has identified.
“Awareness of the signs of sepsis and early detection and treatment are key to beating it.”
Christopher added: “Kim was the most loving and affectionate wife. We were inseparable and did everything together.
“We had always spoken about how many children we wanted. We both wanted a big family and were so overjoyed when our daughter came into our world.
“I still cannot really believe how just a little over two weeks since the arrival of our beautiful daughter, Kim had died.
“Her death has left us all devastated but what is even more heart-breaking is that Kim is no longer here to see our daughter grow up. Kim will not be here to share all the major milestones like our daughter’s first day at school, passing her exams and getting married is the hardest thing to come to terms with.
“Kim will always be part of our family and our daughter will grow up knowing how much Kim loved her and how proud she would be of her.
“It is difficult not to feel angry that if Kim would have received the care she deserved that she could still be alive. All our family can hope for now is that Kim’s death is not in vain and the Trust ensures it learns lessons.”
The Hospital Trust’s report contained 12 recommendations for improving care including:
- All maternity staff receive training to ensure they recognise sepsis
- A review undertaken to establish how the hospital can implement national NHS guidelines of a consultant reviewing all emergency patients within 14 hours
- A maternity consultant should be consistently involved in the care of sick women
- The senior management team undertake a review of record keeping
HM Senior Coroner for Essex Mrs Caroline Beasley-Murray returned a narrative conclusion.
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Kimberley, a care home administrator, and Christopher, had been together since they were teenagers and married in 2014.
At around 11.30pm on 1 April, 2018, Kimberley’s waters broke. She and Christopher went to Colchester General Hospital. Following an examination they were sent home as natural labour had not started and told to return within 24 hours if there was no movement.
The following night the couple returned. Kimberley was induced. After staff raised concerns about her baby’s condition an emergency caesarean was performed on 3 April. Christopher and Kimberley’s daughter was born healthy on 3 April.
Kimberley was discharged two days later despite her and Christopher raising concerns about the amount of pain she was in.
Christopher took his wife back to the hospital on 7 April concerned she looked jaundiced. She underwent an iron transfusion the following day.
On 11 April they returned to the hospital after Kimberley started bleeding. She was diagnosed with a possible womb infection and given oral antibiotics before being sent home.
Two days later she attended a midwife appointment when it was noted her caesarean scar was healing well, a serious incident investigation report published by East Suffolk and North Essex NHS Foundation Trust said.
Four days later Kimberley continued to feel unwell. She was taken to A&E at Colchester General with a body temperature of around 40 degrees and a high heart rate. The ambulance crew radioed ahead saying she had suspected sepsis. She was admitted to the maternity ward.
The serious incident investigation report said Kimberley showed “evidence of abnormality”. However, no comments were made in her medical notes about these abnormalities. It was not clear if this was because there were not noticed or the “significance of them was not recognised” by staff.
Kimberley was placed on I-V antibiotics which were changed later that following morning. That afternoon she was seen by a critical care team doctor but no written notes from the doctor were made, it added.
Shortly afterwards Kimberley was seen by an intensive care doctor who did not feel it was necessary to transfer her from the maternity ward to critical care, the Trust said.
At around 8.50pm on 15 April a more senior intensive care consultant examined Kimberley. Their notes did not include examination findings. They recommended that a pelvis and abdomen CT scan was carried out but these this was not started until nearly 11.15pm, the Trust report found.
In the early hours of 16 April Kimberley was transferred to the critical care unit. However, no notes were written by anyone involved in that decision, the report said.
Later that day and more than 10 hours after “last input” from a critical care unit doctor, a consultant reviewed Kimberley. The notes were “sparse and written by a junior doctor,” the hospital report added.
The doctor believed an infection of the womb was the most likely diagnosis.
Kimberley’s condition continued to deteriorate. Around lunchtime on 17 April a consultant concluded that the “logical explanation” was that Kimberley was suffering from endometritis and sepsis. She was receiving maximum antimicrobial treatment and “failure to locate source of the infection would lead to a very poor prognosis,” the report said.
Christopher said the family were advised Kimberley needed surgery to investigate her abdominal pain and she may want to consider undergoing a hysterectomy. However, there was an 80 per cent chance she would not survive.
Kimberley was suffering from multiple organ failure. At around 6pm on 17 April she underwent exploratory surgery and a possible hysterectomy. She was at “very high risk” and may die. However, the Trust said not operating was “not an option” “given the undiagnosed and unachieved sepsis control”.
During surgery doctors found and removed small parts of her placenta. It was deemed too risky to continue with a hysterectomy. Tissue samples were taken for analysis.
Kimberley’s condition continued to deteriorate. Throughout 18 April several discussions among a number of medical staff were held. Doctors agreed to perform a hysterectomy. Kimberley died on her way to theatre, the report said.
The results of the tissue samples came back shortly after she died.