Assistant coroner for Blackpool & Fylde Louise Rae’s prevention of future deaths report was published on this week in the wake of the death of Sarah Dunn on April 11 2020.
At an inquest in November 2021, Ms Rae determined the 31-year-old died due to “natural causes contributed to by neglect”.
Her cause of death was recorded as “streptococcus sepsis following medical termination of pregnancy”.
In her record of inquest, the coroner notes Ms Dunn was admitted to Blackpool Victoria Hospital in Lancashire, on April 10 2020.
She was suffering from a streptococcus infection caused by her early medical abortion on March 23 which had produced sepsis and toxic shock by the time she was admitted to hospital.
The coroner says “signs of sepsis were apparent” before and at the time of Ms Dunn’s hospital admission – but she was instead treated as a Covid-19 patient.
The coroner states: “Sepsis was not recognised or treated by the GP surgery, emergency department or acute medical unit and upon Sarah’s arrival at hospital, the sepsis pathway was not followed.”
Ms Dunn did not receive antibiotics until seven-and-a-half hours after arriving at hospital. She suffered a seizure before she was transferred to the intensive care unit, where she later died.
Under a section of the report headed “coroner’s concerns”, Ms Rae cites “inadequate training of doctors and other medical professionals” about the risk of sepsis following abortions.
She said evidence from a “wide range” of clinicians who cared for Ms Dunn “revealed a common theme of lack of training, knowledge or experience on the part of physicians and medical staff (including GPs, pharmacist and acute hospital doctors) regarding the rare risk of sepsis following early medical termination”.
The coroner added: “The hospital trust accepted that at the time of Sarah’s death, there was confirmation bias in their thinking due to the Covid-19 pandemic and that other differential diagnosis were not considered in this case.
“Whilst the witness evidence was that sepsis protocols were in place at both the GP surgery and the hospital trust, what is of particular concern is that none of the professionals who saw or spoke to Sarah were considering sepsis in this case.
“Sarah was spoken to and seen by numerous medical professionals in both primary and secondary care but no sepsis protocols were initiated and I found that the compounding delays in screening, diagnosis and treatment more than minimally contributed to a poor outcome in Sarah’s case.”
She added: “I am concerned that there remains a lack of awareness of sepsis, in particular following early medical abortion, given how many opportunities there were to think sepsis in this case.”
Pete Murphy, Blackpool Teaching Hospitals NHS Foundation Trust’s executive director of nursing, midwifery, allied health professionals and quality, said: “Our thoughts are with Sarah’s family and I want to personally send them my sincerest condolences at this difficult time.
“We did receive a legal notice designed to help prevent future deaths in similar circumstances following the inquest.
“It doesn’t feel appropriate for us to comment in more detail until the full process has been completed by the Department of Health and Social Care.”