Coroner warns NHS Trust of potential risk to patient safety following death of student nurse Zoe Bell

Senior Coroner for Buckinghamshire, Crispin Giles Butler raised concerns that patient care could be impacted if bosses at Stoke Mandeville Hospital failed to continue to carry through their commitments around scans, decision-making and record keeping.

At the inquest into Zoe’s death, Senior Coroner Butler concluded that Zoe died from flu combined with Staphylococcal Aureus Septicaemia (secreting the PVL toxin), Bronchial Pneumonia and an acute lung injury which were not treatable by the hospital in the timescale after her arrival there.

Zoe, from High Wycombe, died 20 hours after arriving at Stoke Mandeville Hospital where she worked shifts. She had spent more than 12 hours in the A&E department waiting for a full clinical assessment. During that time, her boyfriend pleaded with hospital staff to give her care, an inquest heard. Despite this, Zoe remained in the A&E waiting area.

It was only after Zoe’s condition seriously deteriorated, and her x-rays were reviewed at 10am on Christmas Eve that she was rushed to a resuscitation bay before being taken to the intensive care unit. Zoe died in surgery at 6.45pm that day.

In a letter recently sent to the Chief Executive of Buckinghamshire Healthcare NHS Trust, Senior Coroner Butler acknowledged the efforts the Trust said it had made following a review of Zoe’s treatment, however he warned that promises to improve emergency care must be carried through. In particular, he highlighted:

• The timing of decisions and actions
• Procuring x-rays and other scans
• Accurate record keeping

The coroner raised concerns that if these promises were not acted upon, it could impact the care of patients in the emergency department.

Zoe Bell’s father, Nick Bell received a copy of the letter and said:

“Zoe had a bright future ahead of her. As a student nurse in her final year, she was excelling in her studies and was passionate about caring for others. We know she would have gone on to do

more incredible things in her nursing career. Zoe was tragically taken from us at the hospital where she trained and worked.

“In the days following Zoe’s death, when we asked for Zoe’s case to be referred to the Coroner, it was our heartfelt wish that lessons could be learned from Zoe’s death so that no other family has to go through a similar tragedy in future.

“Now that the inquest process has concluded, it is difficult to accept that an otherwise healthy 28-year-old can go to A&E with a viral infection and pass away within 20 hours and that this was ‘not treatable’ in the timescale from arrival. Zoe’s sudden passing was caused by complications from flu, worsened by the rapid onset of additional serious infections and then fatally sepsis.

“The inquest process has shone a light on significant failings in Zoe’s care in the first 12 hours in A&E and in how chest infections and sepsis are diagnosed and treated. We hope that this will raise awareness of the serious risks associated with these illnesses, especially in otherwise healthy young people and how urgent diagnosis and treatment are essential.

“This has highlighted the importance of the learnings of how serious illness can be overlooked in young people whose bodies work very hard and compensate for how ill they actually are, and we want doctors to have greater awareness of the symptoms of infections in healthy young people who can sometimes mask these signs.

“We want to empower patients and families, who may be best placed to notice changes in their loved one’s condition, to raise their concerns, and for medics to take greater account of the concerns of patients and their families and to understand the importance of listening to patients and families concerns.

“A severe lack of observations in Zoe’s case has highlighted the importance of regular observations being undertaken and recorded to monitor deterioration in patients.

“Due to Zoe’s presentation on arrival at hospital with a chest infection she was always due to have an x-ray. The x-ray took 12 hours to be reviewed and acted upon, by which time, Zoe was seriously deteriorating and opportunities for earlier diagnosis of sepsis were missed. This has highlighted the importance of x-rays being taken at the earliest opportunity and being acted upon immediately and for patients and families to push for this vital examination to be taken at the earliest opportunity.

“It is our hope and wish that urgent actions and learnings are not only implemented but embedded and that changes are made to the way A&E departments are run, not just at Stoke Mandeville, but nationally in light of Zoe’s death.

“Zoe was a beautiful and delicate young woman; her absence leaves a hole in our lives that can never be filled. But we know Zoe’s legacy, the kindness and love she showed others, will live on in those lives that she touched. We will forever cherish our memories of her and carry her in our hearts always.”

The family’s lawyer, Megan George an associate solicitor of Leigh Day said:

“During the inquest, the Trust gave evidence of current and planned changes to help ensure that the failings identified in Zoe’s care would not be repeated in future. Whilst we welcome these proposed changes, we concur with the Senior Coroner’s warning that if these are not implemented then there is a risk to the safety of future patients.

“We would urge the Trust to ensure that these lessons are not forgotten, and that all the proposed changes are implemented in a timely manner, in memory of Zoe’s legacy and for the future patients and families who will be impacted by her story. “