'Serious omissions' were made in the care of a 'healthy' Nottinghamshire mum in the lead up to her death in hospital, an inquest has found. Jodie McCann, mum to four-year-old Freddie, had just enrolled to start training as a nurse when she was admitted to King's Mill Hospital, Sutton-in-Ashfield, in March with acute pancreatitis.
She died aged 22, after a breathing tube became dislodged during her care at Queen’s Hospital in Burton-upon-Trent. The student nurse, of Newark, Nottinghamshire, had been admitted to the hospital's intensive care unit from King's Mill on March 22 last year after suffering a cardiac arrest while undergoing treatment for gallstone pancreatitis.
Leading the inquest at Nottingham Council House, Dr Elizabeth Didcock told the hearing: "She remained critically ill, but she was improving." It was a 'reasonable decision', Dr Didcock told the hearing, to extubate Ms McCann on March 28. Extubation is the process of taking out a tube that helps one breathe.
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However, the patient then struggled with breathing, and required reintubation later that evening at 11pm. It was down to the two junior doctors who were on call to perform the procedure, while the coroner said the reintubation should have been done by a consultant.
This was a "challenging" procedure for Ms McCann, who had suffered a short hypoxia, meaning she had insufficient amounts of oxygen at the tissue level, Dr Didcock explained. The mum of one underwent a tracheostomy, however, the flexible breathing tube was displaced at some point.
"This was a serious omission of care", Dr Didcock told the hearing. She also raised concerns over the lack of planning in Ms McCann's care at the hospital.
It also became apparent that a small tube in the airway trolley was missing at the time of the procedure, the inquest found. A doctor then proceeded to perform 'escalating airway manoeuvres'.
Delivering her findings after a three-day inquest on Wednesday, April 19, Dr Didcock added: "On the balance of probabilities, it is likely that Jodie would have survived." However, Ms McCann was declared deceased at 5.50 on April 2.
She has highlighted "serious issues" in Ms McCann's care at the Queen's Hospital, adding: "She should not have been intubated by a junior consultant."
The coroner also raised her concerns over the airway trolley that had equipment missing. A plan has been sent to the coroner in prevention of future deaths report, however, Dr Didcock said there is "limited progress" made by the trust.
She concluded the inquest by thanking the family and witnesses who attended the hearing virtually. Ms McCann's mum, Sloane Warbrick, 41, said in a statement: “It’s almost impossible to find the words to describe our loss and what the last year has been like without Jodie. Not only was she my eldest child; she was also my best friend.
“It’s still difficult to try and understand how she went into hospital and never came home. Jodie was beautiful inside and out. She always saw the best in people and went out of her way to help others. That’s why she wanted to become a nurse.
“There’s not a day goes by where we don’t think of Jodie. Life will never be the same without her. The inquest and listening to the evidence around her death is something no parent should have to go through but it was something I had to do not only for Jodie but for Freddie.
“That she’s not here to see him grow and won’t get to celebrate life’s milestones is the hardest thing to accept. Jodie would be so proud of Freddie. While he’ll grow up without his mum in his life he’ll always be told how much Jodie loved him and how she’ll always be a part of our family.
“I just hope that by speaking out improvements in care can be made. I wouldn’t wish what our family are going through on anyone.”
Sreeman Andole, Interim Executive Medical Director at University Hospitals of Derby and Burton NHS Trust, which runs Queen's Hospital, said: "Jodie needed and deserved a far better standard of care than was provided to her and we are truly sorry for these failings.
"Our commitment to Jodie's family and our community is that we will build on the changes we have already made, and learn from Jodie's tragic case. We accept the Coroner's findings in full and we have a clear action plan in place to continue to address the concerns and make the further improvements needed as a priority."
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