Sitting alone at his eating desk, utilizing a system of colored Post-it notes, Antony Higginson started to map out what he did and didn’t find out about his spouse’s demise.
That afternoon his GP had handed him a duplicate of her autopsy report. It confirmed that 12 days earlier than her sudden demise at Whiston Hospital, Merseyside, three months earlier, she had acquired a dangerously excessive dose of paracetamol for somebody of her dimension. It was the primary time he was made conscious of the error.
For the 49-year-old former soldier, who served with the Royal Dragoon Guards in Northern Ireland, this began an seven-year battle for the reality, which he describes as “my final tour of obligation”. He has spent £80,000 on attorneys and impartial medical consultants to problem the NHS view that the overdose didn’t trigger his spouse’s demise.
Laura Higginson together with her daughter, Evie, in 2012
JON SUPER FOR THE SUNDAY TIMES
For 5 days final week, an inquest into her demise heard how she was repeatedly overdosed by medical doctors and nurses who then carried out an uncommon autopsy with out the household being instructed concerning the errors. The case, at Bootle city corridor, is being overseen by the fourth coroner to be concerned.
It can now be revealed that an earlier police investigation and overview by the Crown Prosecution Service discovered 12 members of NHS workers — two medical doctors, 9 nurses and one pharmacist — all failed of their obligation of care to Laura Higginson. But the CPS concluded the case didn’t meet the edge for legal prosecution.
• The NHS is stuck in a cover-up culture — there is a better way
Laura, 30, a trainee solicitor and mom of two, had beforehand been identified with Gitelman syndrome, a situation that impacts the kidneys and may contribute to a sufferer being smaller than common. She weighed 36kg — slightly below six stone — and was 5ft 1in tall.
Higginson says he has “damaged” himself combating for solutions
On April 5, 2017, she went to A&E after a number of days of feeling unwell and vomiting and was admitted to a ward with a analysis of pneumonia.
To ease her fever and discomfort, she was given six 1g doses of intravenous paracetamol — every equal to 2 commonplace 500mg tablets — over two days. Because of her weight, just like a toddler’s, she ought to have been given solely half this quantity. She was repeatedly given grownup doses over two days, a poisonous quantity, earlier than a pharmacist raised considerations. She was then given a seventh dose on the right degree.
Higginson believes the medical institution is attempting to cowl up its duty for his spouse’s demise
JON SUPER FOR THE SUNDAY TIMES
Higginson instructed the inquest that by April 7 his spouse was coughing up blood and had a distended abdomen. She referred to as him from her hospital mattress, fearing she was dying.
He stated: “She was terrified, she was white with concern. I’ve been a soldier in Northern Ireland and I’ve seen that concern on troopers’ faces.” As she grew to become delirious he agreed with medical doctors that she needs to be positioned in a medically induced coma.
He instructed The Sunday Times: “If you realize you’re going to die, as terrible because it sounds, you may depart a legacy. They denied Laura that likelihood. Despite the entire experience of their A&E division and on the wards, they monumentally uncared for Laura from the second she walked in to the second we put the ashes within the floor — and I’ve been combating them ever since.
“This is my final tour of obligation.”
He stated they trusted her medical doctors to get her dosage proper: “On the primary day she was in hospital they have been going to ship her house with antibiotics. I stated no, simply keep in, it’s the finest place to be. I promised her I’d take care of her, and I didn’t. I trusted them and it killed her.”
Laura was rushed to intensive care and given an antidote after the overdose was recognised
JON SUPER FOR THE SUNDAY TIMES
The Health Services Safety Investigations Body, which scrutinises security errors within the NHS, warned in 2022 of the hazards of normal doses of paracetamol being prescribed on wards after the demise of a affected person in her eighties. It discovered 4 circumstances of adults underneath 50kg who have been overdosed.
Paracetamol impacts the liver, which performs a essential operate within the physique’s defence in opposition to an infection. Overwhelming infections can happen within the occasion of liver failure.
Laura’s medical notes present that after the overdose was recognised on April 7, she was rushed to intensive care and given an antidote. But it was too late. She continued to deteriorate and died on April 19.
Dr Sarah Kay, then a junior physician on the hospital belief, reported the demise to the coroner’s service. She instructed the inquest she was shocked that the coroner for Sefton, Christopher Sumner, who has since retired, didn’t tackle Laura’s case for an inquest. She stated she felt uncomfortable.
Laura had been identified with pneumonia
In circumstances of an unnatural demise or the place there’s doubt concerning the trigger, a coroner would usually order a forensic post-mortem, however as a result of the coroner had accepted Laura’s explanation for demise, this was not requested.
The hospital did, nevertheless, order an in-house postmortem to assist determine the reason for demise for its personal information. As Laura’s subsequent of kin, Higginson was requested by the intensive care scientific director, Dr Ascanio Tridente, to consent however was nonetheless not instructed concerning the overdose.
Tridente instructed the coroner he accepted Higginson ought to have been instructed. Giving proof, he insisted that though Laura had suffered “an acute liver derangement” after the overdose the impact was “transient”.
The coroner questioned why, in line with one other guide, Tridente had raised the paracetamol overdose, in a dialog after Laura’s demise. Tridente replied he couldn’t recall the dialog.
• ‘Safe space unit’ to protect NHS staff reporting medical errors
The hospital autopsy was carried out by the pathologist Dr Noori Hassan. He discovered Laura had pre-existing cirrhosis of the liver and concluded: “The prompt staggered paracetamol overdose contributing to her liver damage is feasible however tough to show with certainty.”
At the inquest Hassan instructed the coroner it was very uncommon for medical doctors to request a hospital autopsy. He stated he went together with the request as a result of Tridente “was a buddy, a colleague” including: “If he wasn’t I’d have stated no. It was not applicable.”
Asked why he didn’t ship the case again to the coroner Hassan stated it will have been “an insult and I can’t do this”.
• Why doctors make mistakes — and the questions you should ask yours
One of the nation’s main pathologists, Professor Guy Rutty has since closely criticised Hassan’s work after being requested in 2020 by Higginson for an impartial opinion.
Rutty concluded the postmortem was unreliable due to vital errors. Laura’s date of beginning was incorrect, and her physique weight was recorded as being 23kg heavier. Hassan additionally didn’t take samples for toxicology evaluation, which is a breach of pointers. In proof to the inquest, Hassan disputed Rutty’s findings.
Rutty was so involved concerning the high quality of the postmortem he wrote to managers at Whiston Hospital, however they concluded they’d no main considerations.
In 2019, Higginson went to a second coroner, Graham Jackson, asking for an inquest to be opened. Jackson sought recommendation from the hospital however didn’t ask for any impartial experiences and declined to open an inquest.
Higginson launched a authorized problem in opposition to the choice and the case was raised in parliament, due to the native Labour MP, Derek Twigg. The solicitor-general granted permission for an additional inquest however a 3rd coroner, Julie Goulding, needed to recuse herself due to hyperlinks to consultants concerned within the case.
The fourth coroner, Simon Holder, questioned Whiston Hospital’s assistant medical director, Elspeth Worthington, on Thursday. She admitted there had been a collection of errors in Laura’s care and apologised for a way the household had been handled.
“I can solely maintain our palms up and apologise that no person appeared to instantly focus on the priority of an extreme dose of paracetamol with Laura or her household.”
The coroner instructed her the shortage of transparency over what occurred had a big impact and price: “The penalties of the failures to discharge that obligation. The value to the belief, to the household, the restricted assets of this court docket and the size of this inquest, the associated fee is big all due to that one failing.
“What nonetheless considerations me is the change of tradition required in implementing the statutory obligation of candour when issues go incorrect. We are depending on you implementing that.”
Worthington stated the belief had made adjustments since Laura’s demise.
The inquest will finish on Wednesday and the coroner is anticipated to ship his findings earlier than Christmas.
