'Heartbreaking': My mum suffered & died after routine procedure due to care failures
An inquest into the death of a 58-year-old Leicester mum found she died due to complications following a routine gynaecological procedure, worsened by poor management of her blood thinning medication.
Bridget Stewart died at Leicester Royal Infirmary on 29 February 2024 after more than two years of severe health complications.
Returning a narrative conclusion after a three-day hearing at Leicester Coroner’s Court, HM Assistant Coroner Dianne Hocking found that recognised complications of a necessary procedure were worsened by suboptimal anticoagulation management, including failures to properly stop, resume and monitor blood-thinning medication in line with policy.
Ms Stewart contacted her GP in September 2021 due to irregular and prolonged menstrual bleeding. An ultrasound and MRI scan raised concerns about possible uterine abnormalities, leading to a hysteroscopy in late 2021, following which she was admitted to hospital two weeks later with sepsis.
Following this, the much-loved mother, grandmother and sister experienced serious complications including bowel ischaemia, a condition where the blood supply to the intestines is reduced, requiring emergency surgery in early 2022.
This involved the removal of part of her colon and the formation of a stoma, which profoundly affected her quality of life. She faced ongoing pain, infections and the development of an enterocutaneous fistula, causing significant distress and impacting her mobility and independence.
Ms Stewart was scheduled for reconstructive surgery in February 2024 to improve her condition. However, concerns were raised during the inquest about how her blood-thinning medications were managed in the lead-up to this operation. The coroner heard that the anticoagulation treatment was not adjusted properly according to established guidelines and that consultation with haematology specialists was not sought, despite the complexity of her condition.
This suboptimal management contributed to the formation of a large blood clot in Ms Stewart’s aorta, which blocked blood flow to her right leg. Emergency surgery to amputate her leg above the knee was performed, but her condition deteriorated and she died shortly afterwards.
During the inquest, the coroner acknowledged the complexity of Ms Stewart’s case but found that the issues around anticoagulation were a significant contributing factor to her death. In her conclusion, the assistant coroner praised her family for their strength and advocacy throughout the inquest, stating Ms Stewart would be proud of how they stood by her.
The coroner also raised concerns about the use of two separate electronic systems for recording patient information at the hospital, which risked important details being missed or overwritten. A formal letter of concern will be sent to the trust to urge improvements.
Daughter Amy Jarvis said: “It is heartbreaking to think how much my mum suffered for more than two-and-a-half years following what should have been a routine procedure. She was a strong, intelligent woman who placed her trust in the professionals caring for her.
“Instead, she was let down repeatedly and we had to watch her health unravel bit by bit. We still struggle to understand how things were allowed to go so wrong. We are heartbroken to have lost her in this way and we hope lessons are learned so no other family has to endure the same pain.”
Medical negligence associate solicitor Maryam Abdullah assisted Ms Stewart’s family in preparation for the inquest.
Maryam said: “Ms Stewart’s case is deeply troubling and highlights missed steps in her care, particularly around delays to treatment and suboptimal management of her anticoagulation medication. The delays and inconsistent application of critical medication protocols contributed directly to her deteriorating health and, ultimately, her death.
“We are working closely with Ms Stewart’s family to pursue a civil claim. We hope the coroner’s findings will serve as a catalyst for healthcare providers to rigorously review and improve their protocols to prevent similar failings in the future and improve patient safety.”
Barrister Mass Ndow-Njie, from 7 Bedford Row Chambers, represented the family in court during the hearing.