Saturday, December 03, 2005


In fact, nobody gives a damn -- and it shows

A coroner has concluded that the life of a mother who died of an infection six days after giving birth, could have been saved if she had been sent back to hospital earlier. Jessica Palmer, 34, died as a result of a common infection on June 30 last year, having developed an infection when she gave birth to her healthy daughter Emily. A two-day inquest heard evidence from a midwife who admitted making a "gross mistake" in not raising the alarm, a GP who thought she had sciatica, and a doctor who allowed her home from hospital without taking her temperature.

The Deputy Coroner for West London, Elizabeth Pygott, cast doubt on the "honesty" of one doctor's evidence and highlighted the midwife's mistake but stopped short of formally finding neglect, recording a verdict of natural causes. She told the court that in this case, despite the failure of midwife Karen O'Connor to read the warning signs - a fever and a hot red patch on Mrs Palmer's skin - and tell a GP, she accepted that there had been a "full examination".

Speaking after the hearing, Mr Palmer, an IT consultant, said he was "astounded and surprised" by the fact that the coroner had not recorded neglect. He said: "My wife lost her life in June of last year at a time that should have been filled with joy and expectation for her, for me and our children, and for our families. "Many lives have been shattered by a tragedy that I believe could and should have been avoided."

Miss O'Connor saw Mrs Palmer on June 27, two days before her death, when, had a doctor been told of her symptoms, her condition could still have been treated. The deputy coroner said, based on the evidence of a microbiologist: "Had Mrs Palmer been readmitted on June 27, it is likely she would have been treated with antibiotics and that the death would not have occurred." The hearing was told that Mrs Palmer was deemed well enough to be discharged from Kingston Hospital in south-west London on June 25, the day after giving birth, despite earlier abnormalities in her temperature and blood pressure. Senior house officer Dr Lan-Anh Le concluded Mrs Palmer was "fit and well" without taking her temperature, relying on readings which were already four hours old.

But when Mrs Palmer's husband, Ben, took a reading shortly after she got home, her temperature had soared to almost 40 degrees Celsius and she went to bed feeling "shivery". Mrs Palmer then spent four days at home in a fever with crippling pain in her limbs and back despite speaking to medical staff about her condition, the inquest heard. On the following Tuesday she was finally rushed back to hospital suffering group A streptococcal septicaemia, but it was already too late. By then Mrs Palmer was in septic shock and died of multiple organ failure as doctors prepared to do an emergency hysterectomy.

Community midwife Miss O'Connor admitted in court that she had made a "gross mistake" in not raising the alarm to a GP on the Sunday when she visited Mrs Palmer, three days before her death. She had been told of her temperature and sore throat and seen an "unusual" red mark on her abdomen. "She was delightful, really delightful. We were laughing and joking. She just said she was very tired," Miss O'Connor told Ms Pygott. She also admitted that she had not taken Mrs Palmer's temperature because she "didn't have a thermometer" but had no major concerns.

GP Dr Sian Williams told how she had spoken to Mrs Palmer over the phone on the Monday morning but, based on what she had been told, believed that she was suffering from sciatica and prescribed a strong painkiller. Dr Williams said Mrs Palmer had described the pain in her back but they had not discussed her temperature. The full seriousness of her condition was not realised until a face-to-face meeting with Dr Carolynne Christie at her GP's surgery on the morning of Tuesday June 29, four days after she had been discharged from hospital. She was rushed to hospital and admitted through Accident and Emergency before ending up in intensive care. As doctors prepared to carry out an emergency hysterectomy she suffered a cardiac arrest in the operation theatre and died.



For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation. Both Australia and Sweden have large private sector health systems with government reimbursement for privately-provided services so can a purely private system with some level of government reimbursement or insurance for the poor be so hard to do?

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