Ms Hannah Barney · Prevention of Future Deaths report

On 17th November 2016, I opened an inquest into the death of Ms Hannah Barney, who died on 11.10.15 (0270-15) (PF) in King’s College Hospital

It was concluded on 6th June 2017. The medical cause of death was:
1a Multi-organ failure
1b Extensive soft tissue bacterial and fungal infection
1c Haemolysis, Elevated Liver Enzyme and Low Platelets syndrome of pregnancy causing liver failure and multiple thrombi; multiple broad spectrum antibiotics
II Genetic Prothrombotic tendency

The conclusion as to the death was by narrative which included: “After intensive medical treatment she was initially referred for surgical debridement of an infected groin haematoma on 11th, which was conducted on 16th and more urgently on 18th, she developed multi-organ failure...”

The evidence of Prof Heneghan was:

Between the 11th and 18th September she was acutely ill and required many specialist opinions and multi-disciplinary care. The tissue viability nurse considered urgent surgical opinion was needed on management of her infected wound. She saw a hepatologist and nephrologist on 12th, a weekend surgical team on call on 13th, the renal team on 15th and a hepato-biliary surgeon in theatre on 16th. The case was then discussed with a plastic surgery registrar, who suggested that an urgent full debridement should be undertaken but this could not be done at King’s College Hospital since there was no on-call plastic cover, and would ultimately need to be performed at St Thomas Hospital. A gynaecology registrar attended on 17th. A scan was performed to exclude necrotising fasciitis and it was agreed that the general surgical consultant would take her to theatre. It was not until 18th when a multi-disciplinary team of gynaecologist, plastics, general surgery and orthopaedics back up was assembled and surgical debridement was performed but she died later in ITU.

The plastics surgical consultant, ████████ who saw her on 18th and 21st gave an opinion that she had haematomas and severe sepsis, although the diagnoses of Fournier’s gangrene or necrotising fasciitis had been considered. These conditions needed very urgent surgical treatment. He said that a few days delay in debridement could make a difference to the damage to surrounding tissues. . General surgeons are often reluctant to undertake such debridements and may not have the skills. He opined that having a sole consultant plastics surgeon practitioner in KCH was not safe. In cases of necrotising fasciitis a small delay in surgery would mean death. He noted that KCH was a regional trauma centre. He considered future lives were at risk without a 24 hour consultant plastics service at KCH.