Ms. Madeleine Lawrence · Prevention of Future Deaths report

On 31st March 2022 I commenced an investigation into the death of Ms. Madeleine Lawrence aged 20 years. The investigation concluded at the end of the inquest on 8th September 2023. The conclusion was that the medical cause of death was (a) Multi organ failure; (b) Group A Streptococcal sepsis; (c) Streptococcal necrotising myositis; II Traumatic native hip dislocation and the narrative conclusion was ‘Madeleine Laurence died of a rare complication of an infection which developed after she suffered an injury whilst playing rugby. In hospital her deterioration was not recognised and necessary life-saving treatment was not commenced promptly. Madeleine’s death being contributed to by neglect.’

On 9th March 2022 Ms. Lawrence was playing rugby when she suffered a traumatic native hip dislocation following a tackle. She was taken by ambulance to Southmead Hospital, Bristol where underwent reduction of the dislocation under general anaesthesia. The following day she developed pain in her hip and overnight from 10th to 11th March 2022 her condition deteriorated. Observations were not performed for several hours and when undertaken confirmed her NEWS score of 4. The frequency of the observations were not increased and the provisions of NEWS toolkit and the SEPSIS6 protocol were not followed. The NEWS score later increased to 5 and again observations were not carried in a timely manner and prompt treatment for presumed sepsis was not initiated.

When Ms. Lawrence was reviewed on Monday 14th March 2022 it was recognised that she was seriously unwell and she was immediately transferred to the Intensive Therapy Unit. She was treated for sepsis and underwent a number of surgical procedures. Ms. Lawrence was diagnosed with necrotising myositis but despite all efforts her condition deteriorated and she died in hospital on 25th March 2022.

During the course of my investigation I became aware that the NHS Trust had taken steps to increase awareness and training in the NEWS toolkit and the recognition and treatment of the deteriorating patient and sepsis in particular. The focus of the Trust’s efforts had been the ward where Ms. Lawrence was accommodated but that training across the wider Trust was ongoing.

(1) That serious deficiencies affecting the safety of patients at Southmead Hospital, Bristol which had been identified following the death of Ms. Lawrence
(2) The CQC should confirm that it is now satisfied that the Trust has addressed the training of current staff and has in place appropriate measures to ensure ongoing training for new staff.