Brandon woman Stephanie Jewell died of multi-organ failure after infection, not communicated to clinicians, took hold
A coroner has described the failure to communicate an infection found in a Brandon 30-year-old a 'clear missed opportunity'.
Stephanie Jewell, of Heath Road, died in the Royal Brompton Hospital in London on August 12 last year after being transferred from West Suffolk Hospital in Bury St Edmunds.
Her death came three months after a burst varicose vein left her with an open wound and a staphylococcus aureus infection took hold.
During an inquest today Suffolk Coroner's Court heard Miss Jewell, who was born with congenital heart disease and had undergone three open heart surgeries in her lifetime, died of multi-organ failure.
The court was told that on May 16, 2021, Miss Jewell was admitted to West Suffolk Hospital where she was treated for nine days after a vein on her thigh burst.
Throughout her stay, Miss Jewell was also treated for water retention and fluid overload, caused by issues with her liver and kidneys due to her heart problems, and nurses described 'improvement' in this area.
On May 21 she had the dressing on her wound changed and she was then discharged home on May 25.
However, the court heard evidence from Dr Emma Read, Miss Jewell's registered GP, that stated she was seen by a doctor on June 21 after complaining the wound was still not healing.
While the doctor said she presented with no fever, a normal pulse rate and respiratory levels, there was some redness around the wound and so she was prescribed the antibiotic flucloxacillin.
On June 25 another doctor at the practice saw Miss Jewell and noted the wound had begun to heal and had no redness or swelling.
However, on July 7, Miss Jewell called again, complaining of itching and heat coming from the wound and suggested the infection may have returned.
She expressed concerns that an infection could lead to infective endocarditis, where infective bacteria settles in the heart lining which those with heart diseases are more prone to.
Miss Jewell was prescribed further antibiotics and a swab was performed on the site which confirmed she was suffering from a staphylococcus aureus.
But the court heard Miss Jewell's other consultants, including those at West Suffolk Hospital and the Royal Brompton, were not informed of this finding by the GP.
On July 21 Miss Jewell presented at West Suffolk Hospital A&E after another bleed from the vein.
Dr Jonathan Boyle, the consultant who saw her during this visit, described the bleeding as 'controlled' and planned for Miss Jewell to be seen at Addenbrooke's Hospital in Cambridge on July 29 for a scan and treatment.
On that date, Miss Jewell had a sclerotherapy procedure - where a substance is injected into the site to shrink and close off the vein - which went ahead without complications.
However, just four hours later, the inquest was told Miss Jewell returned to A&E 'extremely unwell' with a high fever and signs of sepsis.
She was stabilised at West Suffolk Hospital and then transferred to the Royal Brompton where, despite treatment, she died on August 12.
Dr Boyle said there was no evidence in records that staff who did the sclerotherapy procedure noted any signs of infection at the time and called it 'extremely unlikely' that the injection played any part in the infection.
He said: "I'd be fairly confident that my colleagues wouldn't have gone ahead with the procedure if she seemed unwell at the time."
"This is a very sad case and from my perspective we were all trying to do our best to prevent something that might've been life threatening," he later added.
In court today, Dr Isma Rafiq, a consultant cardiologist from Royal Brompton where Stephanie was a registered patient and visited specialists, said she and other clinicians were never informed of the infection by the GP.
In fact, Dr Rafiq said she was not told Miss Jewell had an open wound until she was transferred into the hospital.
While Dr Read told the court it was not the surgery's practice to do so, Dr Rafiq said knowledge of her GP consultations would have been 'helpful'.
Dr Rafiq told the court when Miss Jewell arrived at Royal Brompton they found 'pockets of infection' all over the heart and found seeding of infection in the lungs.
When asked if she thought the leg wound should have been dealt with earlier, she said: "I think it should have been dealt with earlier, yes. I totally agree with that."
Coroner Nigel Parsley branded the incident a 'failure to communicate' and called it a 'clear missed opportunity', but said evidence did not show the outcome would have been any different if the information had been passed on.
Mr Parsley confirmed the death was caused by multi-organ failure as a result of infective endocarditis (heart infection) contributed to in some way by complex congenital heart disease and hepatic cirrhosis (scarring of liver).
He concluded Miss Jewell died of natural causes and called her death "tragic."