An inquest into the sudden death of a previously healthy 19-year-old was told she faced a catalogue of issues with health care.
A coroner ruled Holly May Maxwell, of Spalding, died due to natural causes from having sepsis, influenza, pneumonia and COVID-19 days before Christmas last year.
But the inquest at Boston Coroner’s Court was told she visited her GP surgery three times, but failed to see a doctor, received no treatment and faced a six-hour wait for an ambulance.
She was then taken to Boston’s Pilgrim Hospital, which was under-staffed at the time, the hearing was told.
The hospital says it has now made a host of changes to how it deals with cases as a result of Holly May’s death.
She first attended Munro Medical Practice on December 5 with cold like symptoms and then returned on both December 15 and December 16 as her condition worsened.
On each occasion she saw a clinician rather than a doctor and was only diagnosed with “mild fever” on her final visit.
Two days later the same clinician said Holly needed urgent attention when she attended Spalding Urgent Treatment Centre (UTC). By then Holly had no appetite and could not sleep.
She was given her first antibiotics there and told to go to hospital, however, despite being the second highest category of emergency out of five, there was a six-hour wait for an ambulance.
“There’s been horrendous delays with the EMAS service,” said coroner Paul Cooper at the inquest. “Six hours is not unusual for me to hear for a delay.”
After an hour her family was able to find a lift to get her to Pilgrim Hospital.
The family told the inquest that she was sent with a written note of her symptoms but the hospital downgraded the severity of her conditions to a lower level.
The hearing heard while waiting in A and E with only one nurse overseeing 23 people, Holly May suffered a cardiac arrest.
“That was totally unacceptable,” Mr Cooper said. “It just added to the situation she found herself in.”
She was taken to Intensive Care and doctors gave her just a five per cent chance of survival, something not communicated to her family.
A close family member said they were shocked to be told the next day (December 19) that Holly May had “three to four hours” left, but she then died 45 minutes later after a second cardiac arrest.
Dr Rajeshwar Ranganathan of United Hospitals NHS Trust, which runs Pilgrim Hospital, told the hearing he’d only seen three patients that had all of sepsis, influenza and COVID-19 and two of those had died due to the immunisation system being overwhelmed.
That Holly May also had a vitamin B deficiency would also have weakened her system, he said.
Dr Ranganathan said that measures since implemented by Pilgrim Hospital included Spalding UTC now phoning ahead when they send someone to Pilgrim and that no medication be delayed more than 60 minutes on arrival of a patient. The change was made as Holly May had to wait longer than advised for more antibiotics.
A specified waiting area had also been created in A and E so staff there would know who the most critical patients were and that more staff would be on at weekends. Holly May was admitted on a Sunday.
“Since this incident and a couple of incidents after we’ve added extra shifts,” he said. “In the waiting area at that time there was one nurse looking after 23 patients. It’s meant to be up to one nurse per eight in a waiting area.
“A single nurse looking after 23 is completely not acceptable.”
Coroner Mr Cooper ruled Holly May’s death was from natural causes as he decided from evidence presented she was already too ill to be saved by the time she reached Pilgrim.
He also said he would be writing to the Munro Medical Centre.
He said to the family present at the hearing: “You won’t be the first family that’s said we’ve been to A and E and we’ve been asked to sit down and wait where people have been collapsing.
“The perception of A and E is they’re overworked at this moment in time, you have to wait a long time and it’s not the service it used to be.
“Unfortunately you’re one of those families that the actual reality of the scenario has caught up with it.
“The perception I have is that the hospital had failings in not treating quickly enough and were presented with something they couldn’t deal with.
“My perception is Holly May should have been referred to the GP on at least the third occasion, if not the second, but wasn’t referred at all.
“The GP could have taken some pre-emptive action and straight away treatment could have taken place.
“Whether it would have saved her life or not is a million dollar question that we can’t answer.
“She might have been given a better fighting chance.
“Unfortunately we can’t bring Holly May back. Steps have been put in place to ensure this won’t happen again.
“She could have been better looked after in the hospital but whether that contributed to her death is another matter.
“With everything she stood little chance unless everything went very well, which it didn’t.
“It’s a horrendous thing for a family to go through and it happened so fast and was totally unexpected.”
In a statement following the hearing, Dr Graham Wheatley of Munro Medical Centre, said: “The coroner has written to us asking for further information and we have provided a full response.
“Although Holly May is still entitled to confidentiality, I can say that she was assessed over the four consultations (including the last one at the Urgent Treatment Centre) by two of our most qualified and experienced clinicians.
“In general terms, in situations where there are clinical features or a positive lab result of Strep A infection, we would prescribe antibiotics.
“After reviewing Holly’ May’s care, we are confident that this was not the case for her, until the final consultation, and we have written to the coroner to confirm this.
“Of course, we are devastated by her death, and have sent condolences to her family.”
A statement to the inquest about Holly May described how she adored her family and friends.
After working in childcare and at a care home previously she had been looking for a career helping those with mental health issues.
“Holly May was truly beautiful inside and out,” the statement said. “You can feel her energy whenever she was near.
“She was lovely, outgoing, funny and just simply like no other, someone who wanted to try all things new and her whole world was her friends and family.
“She enjoyed life as every 19-year-old should and was eager to taste all that it offered.
“Holly May was very kind natured and always put other people before herself.
“She always looked forward to the Christmas period and spending time with both sides of her family while balancing her social life with friends.
“She was a bright shining star who loved life, was kind-hearted and so much fun to be with. She was a positive person always looking to the future with a huge to do list.
“Holly May was taken from us so quickly and unexpectedly and everyone is bewildered and shocked trying to come to terms with all that is lost to us.”
