Page last updated at 16:36 GMT, Thursday, 12 June 2008 17:36 UK

Woman's death following abortion

Coroner's report - generic
The inquest heard how Miss Jones was waiting for a blood transfusion

A teenager died a fortnight after having an abortion because of delays in giving her a vital blood transfusion, an inquest in Bristol has heard.

A-level student Manon Jones, 18, from Caernarfon, Gwynedd began to bleed after the operation and admitted herself to hospital, where she died.

A doctor told the inquest the Southmead Hospital ward in Bristol had been busy and "things could have been different". Miss Jones died in 2005. The coroner recorded a narrative verdict.

Manon found it very hard to make a decision to terminate the pregnancy. She wanted to keep the child but there were difficult circumstances which she had to consider with her boyfriend's family and their Muslim religion
Llywela Jones
Mother

Coroner Brian Whitehouse said this was one of the saddest cases he had had to deal with in almost 40 years.

The inquest heard how Miss Jones, a Christian who had an active social life with the church, had decided to terminate her pregnancy because she had concerns for her boyfriend and his family, who were Muslims.

Her mother Llywela Jones said: "Manon found it very hard to make a decision to terminate the pregnancy. She wanted to keep the child but there were difficult circumstances which she had to consider with her boyfriend's family and their Muslim religion."

Two weeks after the procedure she went on holiday, against medical advice.

She cut short her break after feeling ill and returned to Bristol, where she was a student, and admitted herself to Southmead Hospital.

Initial blood tests taken at the hospital failed to alert medics to any serious condition, the coroner heard.

But more tests showed she needed a blood transfusion.

Wait

However she was left waiting for the blood when another emergency broke out on the ward and her condition deteriorated, resulting in her needing life support.

Post-mortem tests showed she died of low haemoglobin levels and shock caused by "retained products of conception" - that is the embryo.

Dr Lucy Jackson, who treated her at the hospital, said the results of an initial blood test did not immediately lead her to consider low haemoglobin levels.

She said Miss Jones talked coherently when she arrived and bleeding was minimal.

Following a second blood test, Dr Jackson decided a blood transfusion was immediately required but Miss Jones was stable enough to "wait for the blood to arrive".

The doctor was pulled away from Miss Jones when an emergency broke out elsewhere on the ward.

'Extremely busy'

An emotional Dr Jackson told the inquest: "If we hadn't been so busy, particularly with the other emergency, we would have had more time and things could have been different."

The inquest heard from Dr Richard Porter, an obstetrician at Royal United Hospital, in Bath.

He did not treat Miss Jones, but said it had been "wholly inadequate" to leave her waiting for a blood transfusion for more than four hours.

But, the doctor said, it was "hard not to conclude" that Miss Jones would have survived had she not gone on holiday and had she attended hospital earlier.

The coroner was told scans - which had since gone missing - indicated there were no problems.

Miss Jones's mother recalled how she had packed her daughter's suitcase and taken her to the railway station.

Life support

"I was very worried about her. She said she was cold again and a bit light-headed," she said.

"We both held on to each other and the train doors were closing on our hands as I stood on the platform as the train was leaving. It was the last time I saw her alive."

Mrs Jones told the coroner she went to the hospital when her daughter was gravely ill and stayed at her bedside until a decision was made to turn off Miss Jones's life support on 27 June.

The coroner said the death was not due to natural causes and a verdict of misadventure would have been inappropriate.

He said the narrative verdict was because Miss Jones died as a result of retained products of conception following the termination of a pregnancy.

The coroner discussed the issue of neglect and said he did have concerns.

He said an earlier transfusion of blood would have been likely to have saved her life.

He also said that it was unsatisfactory that scans had gone missing.

Condolences

But he said there was no failure on the part of the NHS trust to provide basic medical care and it was certainly not a gross failure.

Following the inquest, the North Bristol NHS Trust said it accepted the coroner's findings. It said an investigation had been carried out into the care given to Miss Jones.

It said since the "unique case", further measures had been brought in to ensure seriously deteriorating patients were identified early and prompt action was taken.

It offered its sincere condolences to Miss Jones's family.





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