Family Calls For Lessons To Be Learned Following Inquest

An aspiring paramedic died from sepsis hours after attending an out of hours GP service displaying ‘red flags’ of the infection, an investigation found.

Jessica Holbrook, 23, visited surgeries run by out of hours’ provider i-Heart Barnsley twice in the days before her death after complaining of a cold, sore throat and tickly cough.

On her second visit, despite showing ‘red flags’ of sepsis, Jessica was diagnosed with tonsillitis and sent home, an investigation found. She sadly died the following day.

Jessica’s family have now joined their legal team at Irwin Mitchell in calling for lessons to be learned and that all medical staff are aware of the symptoms and dangers of sepsis.

It follows an inquest into her death in which assistant coroner David Urpeth said there was “gross failings” in Jessica’s care. Recording a narrative conclusion, he ruled  that “Jessica’s death was contributed to by neglect.”

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“Through our work we often see the devastating consequences that families can be left to face because of sepsis.

“The inquest and i-Heart Barnsley’s own investigation raised serious concerns about the care Jessica received and the need for all healthcare providers to recognise the warning signs of this terrible infection.

“We now call on i-Heart Barnsley to learn lessons from Jessica’s death and ensure the recommendations included in its own report to improve awareness and diagnosis of patients with sepsis is implemented. Awareness of the signs of sepsis and early detection are key to beating it.” Sinead Rollinson-Hayes - Associate Solicitor Advocate

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Jessica, of Brierley, worked for Yorkshire Ambulance Service organising routine ambulance appointments, including at Barnsley Hospital as well as in Wath and Wombwell.

Jessica, an avid Barnsley FC fan and season ticket holder, started feeling unwell on Saturday, 9 December, last year. Following an initial phone call with i-Heart, during which Jessica mentioned that she took steroids because she was born without a pituitary gland – which helps the body fight infection - she attended an out of hours GP appointment. She was diagnosed with a viral infection However, no discussions took place about increasing her steroids to help fight the infection, the investigation report said.

Jessica, who had sat exams to become a paramedic, had been staying at the house of her grandmother, Barbara Robinson, on 12 December ahead of a shift at Barnsley Hospital the following day.

However, on 13 December, unusually she called in sick. She attended another out of hours appointment at i-Heart Barnsley and was prescribed penicillin for tonsillitis.

Jessica’s condition continued to deteriorate. The following day an ambulance was called to her grandmother’s house. However, Jessica died before arriving at Barnsley Hospital.

Jessica’s cause of death was due to bacterial infection group A streptococcus. 

An investigation carried out by i-Heart, part of Barnsley Healthcare Federation, found that at Jessica’s second appointment there was evidence she was septic – including a heart rate above 130 beats per minute - but ‘this was not acted on’.
The report found:

• The ‘root cause’ of Jessica’s death, sepsis, was not diagnosed.
• Signs of the infection were present but ‘their significance was not recognised.’
• The staff member who examined Jessica relied on clinical judgment rather than following National Institute for Health and Care Excellence sepsis guidelines.
• The nurse practitioner received limited support in their role
• There was a lack of knowledge around a sepsis ‘tool kit’ designed to help staff recognise the infection

The report made 15 recommendations including:
• Mandatory training for all staff around recognising sepsis
• i-Heart introduce a person to lead on raising awareness of sepsis
• The sepsis ‘tool kit’ is displayed in all clinical areas
• i-Heart takes urgent action to advise no staff member must work outside their competency level.

Following the inquest, Jessica’s dad, Leigh, 49, said: “Jessica was the kindest person anyone could want to meet. It was her dream to qualify as a paramedic and help others. We can’t help but feel angry that when she needed help, she was let down with catastrophic consequences. 

“Jessica’s death has left a huge hole in the lives of everyone who knew her. Our family cannot believe that we will never see her fulfil the great potential she had.

“Our lives will never be the same again but all we can hope for now is that people realise how dangerous sepsis can be. Everyone has heard about sepsis but it’s vital that people actually know its symptoms and the speed at which it can claim lives.

“All we can hope for now is that Jessica’s death was not in vain and that action is taken to improve training so that this cannot happen again to others in a similar situation.”

Sepsis arises when the body’s response to an infection injures its own tissues and organs. Sepsis leads to shock, multiple organ failure and, potentially, death especially if not recognised early and treated promptly.

Signs include slurred speech, confusion, extreme shivering and muscle pain, passing no urine in a day, severe breathlessness and mottled or discoloured skin.