Inquest Concludes If Bowel Injury Found Sooner, Woman Would “Likely Have Survived”

A Birmingham family is calling for lessons to be learned after an inquest found a woman died from sepsis as a result of a perforated bowel three days after undergoing a hysterectomy.

Jessica Bonner was admitted to Good Hope Hospital on 5 October 2023 for a hysterectomy and oophorectomy – removal of her womb and ovaries – as treatment for pelvic pain and fibroids.

The following day, Jessica developed a fever and her heart rate increased.  She also had signs of abdominal tenderness and swelling. 

A CT scan performed the day after revealed a suspected perforated bowel.

Emergency surgery was required to repair Jessica’s bowel.  This was performed during the early hours of the next morning, however her condition continued to deteriorate.  She died on 8 October, aged 51.  A post mortem examination confirmed Jessica died from sepsis as a result of a bowel perforation sustained during her hysterectomy, an inquest at Birmingham & Solihull Coroner’s Court was told.

Medical negligence lawyers instructed to investigate by loved ones

Following Jessica’s death, her loved ones, including partner Jason Large, and her sons, Corey Wilson and Shakil Stevens, instructed medical negligence experts at Irwin Mitchell to investigate her care under University Hospitals Birmingham NHS Foundation Trust, which runs Good Hope Hospital.

Ahead of World Sepsis Day, the family, from Edgbaston, is now joining its legal team in calling for lessons to be learned.

It comes after an inquest concluded that, had Jessica’s symptoms been acted upon sooner, the bowel injury would have been discovered and operated on at an earlier stage.

NHS Trust investigation identifies equipment used during hysterectomy “not approved”

A Patient Safety Incident Investigation Report from the NHS Trust also stated that a piece of equipment used during Jessica’s hysterectomy was “not approved” as part of the Trust’s policies, and that the communication between staff “was limited…compounded by missed opportunities to identify the source of the sepsis.”

Joe Matchett is a specialist medical negligence lawyer at Irwin Mitchell representing Jessica’s loved ones.

Expert Opinion

“This is a truly tragic case which has left Jessica’s family heartbroken.

“Understandably, they’ve had a number of concerns about the care Jessica received and the events that unfolded in the lead up to her death.

“Through our work, we often see the devastating consequences that families can be left to face because of conditions such as a perforated bowel and sepsis. Sadly, the inquest heard worrying evidence not only regarding the care Jessica received but also regarding communication between medical staff and the use of unapproved surgical equipment.

“While nothing can make up for Jessica’s death, we’re pleased that we’ve at least been able to provide her family with the answers they deserve.

“Jessica’s death is a stark reminder of the dangers of sepsis and how early detection and treatment are key to recovery.

“It’s now vital that lessons are learned from the issues identified by the Hospital Trust in its own internal investigation and the inquest to improve patient safety.” Joe Matchett

World Sepsis Day: Jessica Bonner's story

After her initial surgery, Jessica’s observations recorded a high temperature and elevated heart rate, both indicators of infection.  However, it wasn’t escalated to the ward consultant or surgeon, the inquest heard.

At 10am, Jessica began complaining of severe abdominal pain.  Again, this wasn’t acted upon.

Jessica wasn’t physically examined until after 5.30pm, by which time her abdomen was swollen, indicating a perforation.

An urgent CT scan was ordered, but due to deterioration of her condition, Jessica wasn’t fit enough be transferred.  No referral was made to the general surgeon until 10pm.

Surgery was performed during the early hours of 8 October. Jessica was subsequently transferred to the intensive care unit.  She suffered two cardiac arrests and multi organ failure and was pronounced dead later that morning.

Since Jessica’s death, a number of recommendations were made in the NHS Trust’s Patient Safety Incident Investigation Report. These include a review of the Good Hope Hospital theatres procedures to identify equipment that needs replacing, as well as an audit to ensure all abnormal observations proceed to a higher frequency, such as hourly observations.

Jessica lived with her partner, Jason.  She’s survived by her adult sons, Corey and Shakil.

Grieving son pays tribute to mum

Corey said: “It’s almost impossible to find the words to describe the hurt we feel over mum’s death.

“When she went into hospital for surgery, we never thought she wouldn’t return home. Seeing her in those final days was terrible and we were so powerless to help.

“Trying to grieve for mum while having so many unanswered questions has been incredibly difficult. The inquest and listening to the evidence as to why she died has been traumatic but it was something we were determined to do to at least honour her memory.

“I don’t think we’ll ever got over losing mum in the way we did. To hear the issues she faced in hospital has just added to that upset, particularly finding out that it’s likely she would have survived if her injury had been found sooner.

“We’d do anything to have mum back in our lives but we know that’s not possible. We just hope that by speaking out we can help improve patient care for others. We wouldn’t wish what our family are going through on anyone.”

World Sepsis Day is 13 September.

Signs of sepsis and support available

The charity UK Sepsis Trust says the signs of sepsis include slurred speech, confusion, extreme shivering and muscle pain, passing no urine in a day, severe breathlessness, raised temperature, high heart rate and mottled or discoloured skin.

Find out more about Irwin Mitchell's expertise in supporting families affected by sepsis at our dedicated sepsis claims section. Alternatively, to speak to an expert contact us or call 0370 1500 100.