Jodie McCann: Young mother died after failings by hospital staff

Jodie McCann died on the morning of 2 April last year

A young mother died after a series of failings in her care by hospital staff, an inquest has found.

Jodie McCann, from Newark, was transferred from King's Mill Hospital in Sutton-in-Ashfield to Queen's Hospital in Burton-upon-Trent after she was found unresponsive in bed.

The 22-year-old student nurse suffered a series of cardiac arrests.

University Hospitals of Derby and Burton NHS Trust (UHDB) apologised to her family.

'Difficult' procedure

Nottingham Coroner's Court heard Ms McCann, who had a five-year-old son, "was a fit and well young woman" prior to entering King's Mill for reported gallstone pancreatitis on 16 March last year.

She was found unresponsive and face-down in a bed two days later, and after suffering a cardiac arrest, she then had multi-organ failure.

As the critical care unit at the Nottinghamshire hospital was full, she was transferred to a similar unit in Burton-upon-Trent on 22 March.

After her condition improved, a breathing tube was removed on 28 March, but a tube had to be reinserted at 23:00 GMT that evening, a procedure described as "difficult".

On 31 March, Ms McCann underwent a tracheostomy, which the court heard was "a challenging and lengthy procedure", and at 05:00 on 2 April, the tracheostomy tube became displaced, after which she suffered another cardiac arrest.

After "a further prolonged period of lack of oxygen", when the tube could not be replaced Ms McCann "had a further cardiac arrest from which she did not recover", and was declared dead at 05:50.

Ms McCann was transferred to Burton-upon-Trent as a critical care unit in Nottinghamshire was full

The inquest recorded a cause of death as "prolonged cardiac arrest", with a "hypoxic injury following unsuccessful reintubation after tracheostomy tube displacement", multi-organ failure and gallstone pancreatitis also listed as contributing factors.

Elizabeth Didcock, assistant coroner for Nottinghamshire, said there was "appropriate diagnosis and management" of the gallstone pancreatitis at King's Mill Hospital, with no issues in her care "that caused or made a more than minimal contribution to [the] first arrest, or to her death".

She said Ms McCann's condition while in critical care in Burton was "improving" until the tracheostomy tube became displaced.

"I find that but for the tracheostomy displacement on 2 April 2022, Jodie would not have died," she said.

Ms Didcock pointed to "serious issues of care" while Ms McCann was in Queen's Hospital, including a lack of a plan for her airway management and no organisation for the higher risk of the tracheostomy tube becoming displaced.

She said the "challenging" reintubation procedure "should have been performed by the consultant at that time, or at least he or she should have supervised the junior team who attempted it", and highlighted the lack of a different type of bronchoscope on a trolley for treating difficult airways that affected the ability of a consultant to examine the patient once the tube was displaced.

"Had the smaller intubating bronchoscope been easily available, it is likely that the final [cardiac] arrest would not have occurred, or if it had, it would likely have been of significantly shorter duration," she said.

"On balance Jodie would have survived, certainly over the next few hours and days, and perhaps to discharge, though likely with a degree of neurological deficit."

Ms McCann's mother Sloane Warbrick said her daughter was her "best friend"

Issuing a prevention of future death notice to UHDB, Ms Didcock said efforts by the trust to reduce the risks to other patients following this case had been "insufficient", adding she is not confident there are "robust governance arrangements in place" to review serious incidents.

"There has been insufficient time, in my view, to imbed the changes proposed, and for myself and the family to be confident that the changes will be monitored and maintained," she said.

"I am clear that there remain concerns that circumstances creating a risk of other deaths will occur."

'Truly sorry'

Following the conclusion of the inquest, Ms McCann's family said their lives "will never be the same without her".

Sloane Warbrick said describing the impact of her daughter's death was "almost impossible".

"It's still difficult to try and understand how she went into hospital and never came home," she said.

"She always saw the best in people and went out of her way to help others. That's why she wanted to become a nurse.

"I just hope that by speaking out improvements in care can be made. I wouldn't wish what our family are going through on anyone."

Sreeman Andole, UHDB's interim executive medical director, said the trust accepted the coroner's conclusions, adding it has "a clear action plan in place to continue to address the concerns and make the further improvements".

"Jodie needed and deserved a far better standard of care than was provided to her and we are truly sorry for these failings," he said.