Juliet Saunders · Prevention of Future Deaths report

On 9th March 2020 this Court commenced an investigation into the death of Juliet Saunders, 25 years old. The investigation concluded at the end of the inquest on 30th April 2021. On 9th March 2020, this court commenced an investigation into the death of Juliet Saunders. The investigation concluded at the end of the inquest on 30th April 2021.

I made a determination of a short form conclusion of death arising from natural causes contributed to by neglect. The medical cause of death was:
1a Small Bowel Perforation
1b Volvulus
1c Intestinal malrotation
II Cornelia de Lange Syndrome

On 7 March 2020 Miss Juliet Saunders a 25 year old woman with a genetic condition known as Cornelia De Lange Syndrome was admitted to the emergency department with abdominal pains and vomiting.

Ms Saunders had a complex medical history, her congenital disorder caused a number of factors including a profound learning disability, and an increased likelihood of contracting an intestinal obstruction. Ms Saunders had also undergone abdominal surgery that increased the likelihood of intestinal herniation.

Due to Ms Saunders’ learning disability, no direct history could be taken from the patient. The Trust’s trained learning disability nurses were not available to advice or assist staff as they do not work at weekends.

The emergency department registrar examined Ms Saunders, arrived at a single queried diagnosis of gastritis and commenced a treatment plan.

Abdominal x-rays showing signs of an intestinal blockage were misinterpreted by both the registrar and a hospital radiographer. The images were not escalated to a consultant.

Blood test results which cast doubt on Ms Saunders’ queried diagnosis of gastritis were not given sufficient consideration.

Hospital policies for discharge were not properly followed which allowed Ms Saunders to be transferred to an observation unit without an assessment from a consultant.

Miss Saunders was discharged from hospital, without safety-netting advice, she died at home on the following day.

1. The absence of any support for staff within the emergency department during weekends, in dealing with patients with learning disability.
2. The poor standard of medical record keeping and documentation within the emergency department and observation unit.
3. The failure of systems within the department to allow for the supervision of junior doctors to ensure that complex cases are escalated to more experienced staff.
4. Consecutive failures by medical and radiological staff to recognise abnormal findings within an abdominal radiograph, impacted upon by diagnostic overshadowing.
5. A lack of clinical curiosity, combined with diagnostic overshadowing meant that there was a reluctance to depart from a queried diagnosis of gastritis which led to the failure to diagnose an acute intestinal obstruction.
6. A departure from established procedures to ensure the safety of transfers out of the emergency department to the observation unit.
7. The absence of safety-netting advice to patients leaving the hospital.
8. Ineffective identification of significant failings in care delivered through the Trust’s own Serious Incident Investigation process, leading to a finalised report of poor quality.