Denbighshire: Sara Jones' delayed scan contained sign of serious injury

Sara Anest Jones had a promising background in acting

A woman who killed a nurse and fatally injured herself in a crash had a serious injury missed by doctors.

Sara Anest Jones, 25, died two days after the collision near Bangor, Gwynedd on 31 March 2021.

The inquest in Stoke-on-Trent heard a CT scan report showed free fluid in her bowel area which could have led to diagnosis of the bowel injury.

A post-mortem examination showed Ms Jones had consumed three times the legal limit of alcohol.

Ms Jones, from Corwen, Denbighshire, had crossed into an oncoming lane and collided with a car containing nurse Gemma Pasage Adran and her partner Warren Culato near the Faenol roundabout on the A4.

Ms Adran died from her injuries.

The inquest on Tuesday heard Ms Jones was taken to Ysbyty Gwynedd at 22:07 GMT where a CT scan indicated multiple fractures and a possible liver laceration.

A preliminary radiology report found an injury to her bowel could not be ruled out, with free fluid observed in the bowel area, although this could be normal in women of child-bearing age.

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The CT scan report was not immediately sent to the specialists at the trauma centre in Stoke-on-Trent. There was also a delay in uploading it.

This report was not emailed until 05:35 the next morning, which Dr Nicola Sommers, clinical lead for emergency medicine in Bangor, said was unusual.

Due to the number of fractures she had sustained, Ms Jones was admitted to the trauma centre under the primary care of the orthopaedic team. 

Only a small laceration to Ms Jones' liver was known as a consideration for the general surgery team.

She was not seen in person by a general surgery consultant on ward rounds the following day, who expected the orthopaedic team to tell them of any change in the patient's condition. 

This was described as unusual.

Sara Jones was transferred to the trauma centre at Royal Stoke University Hospital

Despite Sara Jones' family telling staff of her hard, swollen, tender tummy, the surgical team were not called back to see her and her abdomen was not reassessed.  

Blood tests following anaesthetic for orthopaedic surgery had shown a raised lactate level.

The tests should have been repeated but this did not happen until Ms Jones had become unstable, by which time it was too late. 

A post-mortem examination was conducted on Ms Jones' body on 9 April 2021 by Betsi Cadwaladr University Health Board pathologist Dr Muhammad Aslam.

It found that Ms Jones had consumed alcohol at some time before incident and that the measure of alcohol in her blood after the collision was three times over the legal limit. 

The report stated: "The concentration was sufficient to cause a significant degree of intoxication in an average drinker."

That degree of intoxication was said to be a possible contributory factor in causing the road traffic collision. 

Multiple injuries were noted, the most significant being a blunt abdominal crush causing a perforation to the small bowel leading to peritonitis. 

Crush injuries were also noted as reducing the chance of survival. 

'Struggling with spatial awareness'

The inquest heard from Gavin Davies who was a forensic traffic investigator with North Wales Police at the time of the incident. 

His report found that Ms Jones' blue Seat Leon had crossed into the oncoming lane and crashed into the red Honda Civic in which Ms Adran and Mr Culato were travelling in.

He said he could not explain why Ms Jones had crossed onto wrong side of the road. 

A vehicle similar to Ms Jones' Seat Lean car was recorded on CCTV footage driving around Bangor before the incident which was seen to be "struggling with spatial awareness".

His report concluded that the most likely cause of the collision was the "human actions of Ms Jones, which may have been due to her level of intoxication".