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Inquest finds West Suffolk Hospital mistakes were contributing factor in Bury St Edmunds mum's death





West Suffolk Hospital has apologised after an inquest found mistakes were a contributing factor to a Bury St Edmunds mum's death.

Sue Warby, 57, was admitted on July 26, 2018, after she collapsed - following complaints of sickness, diarrhoea and abdominal pain.

She underwent two emergency surgeries for a perforated bowel but her condition worsened over her 35-day stay and was eventually put into an induced coma. She died on August 30 with her husband Jon and sons Brendan and Samuel holding her hand by her side.

Ambulances outside the West Suffolk Hospital in Bury St Edmunds
Ambulances outside the West Suffolk Hospital in Bury St Edmunds

The inquest in January was adjourned. Her husband Jon received an anonymous letter detailing errors in her treatment. He had said ‘questions still remained’ over her death.

Mr Warby said at the time: "This has been a highly distressing time for all of our family and we have been left devastated by Sue's death."

After a long independent investigation by Dr Kenneth Power, senior coroner Nigel Parsley reopened proceedings today. The court heard, while in intensive care, Mrs Warby was given the incorrect IV fluid for 36 hours which caused tests to provide incorrect results. This was exacerbated by the 'poor technique' of staff in drawing blood from the arterial line and failing to fully encounter the 'dead space' which needed to be removed.

West Suffolk Hospital
West Suffolk Hospital

Mr Parsley said this led to Mrs Warby being given doses of insulin medication over a two day period that she did not need. The incorrect insulin dosages being given caused her to suffer low blood sugar which led to a brain injury.

Dr Power was questioned by Conor Dufficy, counsel for Jon Warby, on how the mistakes could have harmed chances of recovery.

The doctor said: “This is a life threatening condition irrespective of any complications sustained," and said Mrs Warby was assessed as having an 84.8 per cent risk of death.

The cause of death was given as multi-organ failure caused by septicaemia and disseminated aspergillus pneumonia. Other significant factors contributing to the death included: Perforated diverticular disease (which had been operated on) with peritonitis, hypoglycemia, pneumothorax, hypertension, and hypothyroidism.

West Suffolk Hospital, Bury St Edmunds Picture by Mark Westley
West Suffolk Hospital, Bury St Edmunds Picture by Mark Westley

Mr Parsley said the hospital's mistakes were a contributing factor but was satisfied with measures they had in place to improve. He said he would write to national medicine regulators and Health Secretary Matt Hancock with suggestions for improvement.

A hospital spokesman said: “We offer Mrs Warby’s family our deepest sympathies. Aspects of her care could and should have been better and we apologise. Since this case we have introduced a series of additional procedures and safeguards, but we will review the coroner’s findings and continue to strive to improve the quality of the care we provide to our patients and their families.”

West Suffolk Hospital said they have: Developed more robust processes for prescribing and checking fluid bags; introduced the use of completely clear medication bags; altered the way in which medication bags are supported and displayed when in use to make them easier for staff to read; changed fluid checking processes in the Intensive Care Unit, and improved processes so that all bags of fluid are routinely changed every 24-hours.

"I hope no other family has to go through what we have.”

Following the inquest, Mr Warby said: Jon “The past two years have been incredibly difficult since losing Sue, and it is still a real struggle to come to terms with her no longer being here.

“The inquest has been a highly distressing time for our family, having to relive how Sue died, but we are grateful that it is over and we now have some answers as to what happened.

“After learning of the errors in Sue’s care, I wanted to know how these occurred and what action was being taken to prevent any similar incidents in the future. The Trust has now made a number of changes which I am pleased about.

“While nothing will ever bring Sue back, the one positive to come out of all this is the action being taken to protect future patients. I hope no other family has to go through what we have.”

For more information on how we can report on inquests, click here.