When Simon Lawrence arrived to visit his 20-year-old daughter, Maddy, in hospital after she suffered an injury in a rugby game, they managed to have a laugh that she had picked up her first “proper” knock.
It seemed a given that she would quickly bounce back, allowing her to carry on with her studies and undergo rehabilitation so she could rejoin her beloved university team. “Yes, it was a serious injury but not a life-threatening one,” Simon said.
But over the next fortnight, Maddy deteriorated dramatically, suffering from an infection that went unnoticed for days and eventually dying of sepsis and multiple organ failure. A coroner concluded that there were “gross failures’” in her treatment at Southmead hospital in Bristol.
“We’re bewildered at how incompetent, uncaring and lax some of the medical staff were,” said Simon, a company director. “That was the really frightening thing, how many of them really couldn’t be bothered to do a decent job. The doctors showed no curiosity at all. I feel terribly naive for trusting them.”
Maddy’s mother, Karen Lawrence, a teaching assistant, said: “She was failed by a number of nurses and medical staff. It beggars belief they didn’t have sepsis foremost in their minds.”
The Lawrences, who are from Petersfield, Hampshire, are calling for sepsis to be treated as a “never event”, meaning it should not occur if national guidance or safety recommendations are followed.
They want training improved on a system called News (national early warning score), designed to pick up sepsis and patient deterioration, and for staff who do not use it properly to face disciplinary action.
The family is also backing “Martha’s rule”, making it easier for patients and their families to get a second medical opinion if they believe their concerns are not being taken seriously by medical staff. “We couldn’t agree more with it. Doctors miss stuff, they are not infallible, they are human beings,” said Simon.
Maddy Lawrence sustained a dislocated hip when she was tackled playing on the wing for UWE Bristol on Wednesday 9 March 2022. She was taken to Southmead and the injury was treated overnight under general anaesthetic.
Simon saw her in an orthopaedic ward on Thursday and after their injury joke became alarmed that Maddy’s pain was not easing – and was apparently not being taken seriously by staff. Her parents believe the hospital concluded that because she was a young, healthy woman, she would be fine.
“But she was a young, healthy woman who was screaming in pain for hours,” said Karen. “She would say: ‘It hurts so much, I don’t know what to do.’ But they saw her as a difficult patient. The wrong assumptions were made. A life was lost because they assumed she’d be OK, she was just being noisy, just being a young girl.”
Maddy’s family believe that by Friday 11 March sepsis had taken hold – and her scores on the News system indicated she should have been screened for the condition.
“All they needed to do at that point was pump her full of antibiotics and she could – would – still be here,” said Simon. “But nobody seemed very bothered about the News scores. The doctors seemed to depend on craft rather than science – the craft of looking at a person and assessing if they were ill or not ill. That was shocking to me. Maybe it testifies to arrogance. They thought they had seen it all. Maddy proved they hadn’t.
“To the outsider News seems a simple system: empirical evidence of where someone is going. This is not some pilot system. It’s been around in various guises for the last decade. It should be front and centre. For something as trivial as keeping an eye on a number, Maddy could still be here.”
Simon says he did not suspect sepsis. “I didn’t even think about it. That’s one of the burdens for me. I really wish I had looked it up on the internet and scared myself stupid then I could maybe have done something different. I took the explanation that her muscles were cramping. I didn’t look beyond that.”
Over the weekend of 12 and 13 March, there was a “sense of drift” in Maddy’s care, her family says. She was hallucinating and still in pain. “The place turns into a ghost ship,” said Simon, who was at her bedside. “Where were the doctors, the senior medical staff?”
The intensive care team took over Maddy’s care from Monday 14 March when doctors finally realised how ill she was. She underwent a series of operations to remove infected muscle and tissue and, finally, one of her legs was amputated.
Maddy’s parents have huge praise for the intensive care team. “They were remarkable,” said Karen. “I thought they were going to pull her through it, they were so on it. It felt like they knew and loved Maddy, even though a lot of them didn’t even see her awake.”
Her family are pleased that at last staff realised that Maddy was a fighter, not a complainer. “In the orthopaedic ward they saw her as a whinging young woman. In ICU they said she was as tough as old boots,” said Simon. “She was such a fighter, trying so hard when her body was being attacked.”
Maddy died on 25 March – 16 days after the rugby accident – with her parents, younger sister, Juliet, and two aunts with her.
The Lawrences are determined that their daughter will not be forgotten. They are considering a request from North Bristol NHS trust to name new training on News after her. “But why wasn’t that training done before?” asked Simon.
They have also set up a charity, Maddy’s Mark, to promote positive mental health and wellbeing in young women through rugby.
“She’s no longer here. We have to accept that,” said Simon. “The fact is, she was having the time of her life. She was loving rugby, loving being part of a team of diverse people. It was a sort of homecoming for her.”
They still have many questions, not least where the sepsis came from. “Having sat there at the inquest hour after hour, I still don’t know the answer to that. I think they don’t know,” said Karen.
She hopes for a time when the awful feelings stop getting worse. “The happiest times are also the ones that bring most sadness because she’s not here. We dip in and out of laughter and tears every day but it’s important for us to stay positive because Maddy was like that and would want us to be like that. I can’t find the words for the pain but Maddy knew she was loved. And she loved us. That is something. But she should still be here with us now.”
