Mum-of-two Jessica Bonner, 51, died after contracting a bowel infection (Image: SWNS)
A mum-of-two died from sepsis three days after undergoing a hysterectomy where surgeons used equipment “not approved” by the NHS.
Jessica Bonner, 51, caught the flesh-eating bug following delays by bungling medics in diagnosing a perforated bowel. She had been admitted to Good Hope Hospital in Sutton Coldfield, West Mids, for treatment for pelvic pain and fibroids in October last year.
Jessica underwent a hysterectomy and oophorectomy – removal of her womb and ovaries – but developed a fever and her heart rate increased the following day. A CT scan performed the day after revealed a suspected perforated bowel which required emergency surgery. However her condition continued to deteriorate and she died on October 8.
A post mortem examination found Jessica died from sepsis as a result of a bowel perforation sustained during her hysterectomy. An inquest at Birmingham & Solihull Coroner’s Court ruled she would “likely have survived” if Jessica’s symptoms had been acted upon sooner.
An inquest has ruled that faster action may have saved Jessica’s life (Image: SWNS)
Her family instructed medical negligence lawyers to investigate her standard of care under University Hospitals Birmingham NHS Foundation Trust.
The trust has now admitted there was “missed opportunities” to identify the source of the sepsis. A Patient Safety Incident Investigation Report also stated a piece of surgical equipment used during the hysterectomy was “not approved” as part of the Trust’s policies, and the communication between staff “was limited”.
Jessica’s partner Jason Large, and her sons, Corey Wilson and Shakil Stevens, from Edgbaston, Birmingham, are now calling on lessons to be learned from the tragedy.
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.
The trust has admitted there were “missed opportunities” (Image: SWNS)
“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 Jessica 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.”
The inquest heard 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 and at 10am Jessica began complaining of severe abdominal pain.
Again, this wasn’t acted upon and 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.
Jessica was subsequently transferred to the intensive care unit. She suffered two cardiac arrests and multi organ failure and was pronounced dead.
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.
Joe Matchett, the specialist medical negligence lawyer at Irwin Mitchell representing Jessica’s family, said: “This is a truly tragic case which has left Jessica’s family heartbroken.
A piece of surgical equipment was “not approved” for use by the trust (Image: SWNS)
“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.”
A spokesperson for University Hospitals Birmingham NHS Foundation Trust said: “We extend our deepest sympathies and a heartfelt apology to the family of Jessica Bonner. Jessica should have received a much greater level of care from our Trust. We are committed to learning, and we will continue to work to improve the care and safety of our services, so that no other family endures the pain that Jessica’s loved ones now face.”
