Sheffield & South Yorkshire

'Failures and neglect' led to woman's sepsis death

Jessica Holbrook Image copyright Family photo
Image caption Jessica Holbrook was working for Yorkshire Ambulance Service when she died

"Gross failures and neglect" by medical professionals contributed to the death of an aspiring paramedic who died of sepsis, a coroner has said.

Jessica Holbrook, 23, died on 14 December 2017 just five days after complaining she had a cold.

Despite being seen at a health centre in Barnsley twice on 9 and 13 December she was not given antibiotics until the day before she died.

Coroner David Urpeth said her death "could and should have been avoided".

Miss Holbrook's father Leigh, 49, said "The fact that something could and should have been done is the hardest thing to accept.

"It would almost have been easier to accept if they had learned that nothing could have been done."

During a two-day inquest at Sheffield's Medico Legal Centre, Mr Urpeth heard Miss Holbrook had been born without a pituitary gland.

The hearing was told as a result she was more susceptible to infection and took steroids to combat the issue.

However, the nurse who saw Miss Holbrook at the i-Heart Centre, Patricia Cusworth, said she "probably didn't give it the consideration required" on 9 December and in hindsight should have given her a deferred prescription of antibiotics during the first examination.

Dr Munir, a Endocrinology Consultant at Sheffield Teaching Hospitals NHS Foundation Trust, said had Miss Holbrook been given antibiotics after the first examination it is "probable" she would have survived.

'Let down'

Recording a narrative verdict, Mr Urpeth said "Jessica's condition was contributed to by neglect.

"Any competent medical practitioner should have know that a patient on lifelong hydrocortisone injections required more help. I am entirely satisfied that the failures made were gross failures."

Mr Urpeth said there were "not just one, but two opportunities to issue treatment, which would have prevented her death".

"She was let down by the medical professionals who should have been there to help her," he added.

Miss Holbrook, from Brierley, worked for Yorkshire Ambulance Service organising routine ambulance appointments but had hopes of becoming a paramedic.

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