"Busy" NHS hospital lets woman bleed to death

A teenager died a fortnight after having an abortion because of delays in giving her a vital blood transfusion, an inquest in Bristol has heard. A-level student Manon Jones, 18, from Caernarfon, Gwynedd began to bleed after the operation and admitted herself to hospital, where she died. A doctor told the inquest the Southmead Hospital ward in Bristol had been busy and "things could have been different". Miss Jones died in 2005. The coroner recorded a narrative verdict....

Two weeks after the procedure she went on holiday, against medical advice. She cut short her break after feeling ill and returned to Bristol, where she was a student, and admitted herself to Southmead Hospital. Initial blood tests taken at the hospital failed to alert medics to any serious condition, the coroner heard. But more tests showed she needed a blood transfusion.

However she was left waiting for the blood when another emergency broke out on the ward and her condition deteriorated, resulting in her needing life support. Post-mortem tests showed she died of low haemoglobin levels and shock caused by "retained products of conception" - that is the embryo.

Dr Lucy Jackson, who treated her at the hospital, said the results of an initial blood test did not immediately lead her to consider low haemoglobin levels. She said Miss Jones talked coherently when she arrived and bleeding was minimal.

Following a second blood test, Dr Jackson decided a blood transfusion was immediately required but Miss Jones was stable enough to "wait for the blood to arrive". The doctor was pulled away from Miss Jones when an emergency broke out elsewhere on the ward.

An emotional Dr Jackson told the inquest: "If we hadn't been so busy, particularly with the other emergency, we would have had more time and things could have been different."

The inquest heard from Dr Richard Porter, an obstetrician at Royal United Hospital, in Bath. He did not treat Miss Jones, but said it had been "wholly inadequate" to leave her waiting for a blood transfusion for more than four hours. But, the doctor said, it was "hard not to conclude" that Miss Jones would have survived had she not gone on holiday and had she attended hospital earlier.

The coroner said the death was not due to natural causes and a verdict of misadventure would have been inappropriate. He said the narrative verdict was because Miss Jones died as a result of retained products of conception following the termination of a pregnancy.

The coroner discussed the issue of neglect and said he did have concerns. He said an earlier transfusion of blood would have been likely to have saved her life. He also said that it was unsatisfactory that scans had gone missing.

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