A hospital trust has been told to take action following the “avoidable” death of a primary school teacher.
Megan Williams had been in and out of hospital several times but died suddenly at her home in Acrise, near Folkestone, following complaints of abdominal pain.
Doctors at the William Harvey Hospital in Ashford believed the mother-of-one had gastritis – but she was in fact suffering from a bowel obstruction caused by previous surgery to remove her appendix in 2009.
It was this undiagnosed issue that ultimately led to the death of the 40-year-old in May 2022, who was described as “simply the best of all of us” by devastated colleagues at Cheriton Primary School.
Now, a coroner has ordered bosses at East Kent Hospitals University NHS Foundation Trust (EKHUFT) to take action and learn lessons from the incident to prevent future deaths.
Although the trust previously admitted her death could have been avoided, the coroner’s prevention of future deaths report highlights issues linking to care and can often be used to instigate change within hospital guidelines.
At an inquest last year, the coroner heard Ms Williams first fell ill on the evening of May 1, 2022.
By 3am the following morning, she was violently vomiting and was taken by ambulance to the William Harvey Hospital.
Her pain levels fluctuated while in hospital, ranging from a five to a 10 on the scale used by medical professionals.
She was discharged the same day, having been diagnosed with gastritis – an inflammation of the stomach lining.
Ms Williams was sick again at about 4pm as she was leaving hospital.
However, this was not recorded in medical documents – something which clinicians later said would have changed their approach had it been known at the time.
She was taken back to hospital two days later, having to be carried by ambulance crews as she continued to struggle with abdominal pain.
Given her recent discharge from the hospital, the teacher should have been seen by a specialist team – but this did not happen.
She is believed to have self-discharged after failing to be seen and left at 1am on May 5. It is not clear whether or not she was fully aware of the danger of doing so.
Two hours later, Ms Williams was sick at home and became breathless at 7.30am. Thirty minutes later, she suddenly sat up and declared she needed to be sick again.
At this point, she collapsed and lost consciousness. Her family and ambulance crews spent more than two hours trying to revive her before she was pronounced dead at 9.58am on May 5, 2022.
A post-mortem examination found Ms Williams died from aspiration pneumonia, a small bowel obstruction and a strangulated internal hernia due to band adhesions from intra-abdominal surgery.
Aspiration pneumonia is an infection of the lungs that can be caused by inhaling saliva, food or stomach contents.
Producing the prevention of future death reports, assistant coroner James Dillon highlighted four areas of concern.
‘Action should be taken to prevent future deaths and I believe you have the power to take such action…’
These include a lack of knowledge among clinical staff of the Acute Abdominal Pain Pathway (AAPP) and there not being a clearly documented and recorded process for patients who self-discharge from hospital.
It was also noted the hospital safety incident process did not include information from family and other interested persons as part of its fact-finding exercise and EKHUFT should provide evidence of what further work has been done to make it clearer and accessible to clinicians.
“In my opinion, action should be taken to prevent future deaths and I believe you have the power to take such action,” added Mr Dillon in his report.
Responding to the points, the trust says “the reinforcement of the AAPP is a continuing process” but has taken steps to make it “readily and easily accessible to clinical staff assessing patients with complaints of abdominal pain”.
It has also “implemented a new process whereby all patients who re-attend the Emergency Department within 48 hours of discharge for the same complaint are seen by the discharging team” alongside updating its policy “relating to patients who self-discharge from hospital”.
It adds: “This review is documented, and forms part of the patients records. This additional process is to ensure that the patient was not discharged when further investigation and/or treatment was required.
“The discharging team will review the patient on re-attendance, ensure no additional investigations are required and either admit or discharge accordingly.
“Since the conclusion of the inquest, the trust has changed the SI [serious incident] process to the new Patient Safety Incident Response Framework”.
It says this has “strengthened the processes to ensure the engagement of the patient, family and other stakeholders with the oversight of the Incident Review Panel”.
Born in Ashford on January 5, 1982, Ms Williams graduated from the University of Bristol in 2003 with a first-class honours degree before going on to travel across Europe.
A charity marathon runner, she then studied at Canterbury Christ Church University – receiving her teaching qualifications in 2013 – and gave birth to her son in 2019.
She also worked in the USA helping clean up after the Hurricane Katrina catastrophe in 2005.
Writing on an online tribute page, a colleague called Jess said: “She was the kindest and most genuinely compassionate person I have ever had the privilege of calling my colleague and friend.
“To see Megan teach was magical. The whole room lit up and both adults and children were equally mesmerised by her passion and love of learning.
“That is rare and beautiful to find in a teacher and Megan just had it.
“The world is a much poorer place without Megan. I feel privileged to have known her and she will forever be missed.”
Glyn Williams, Megan’s brother, said: “My beautiful, amazing sister. It is so hard to accept that you are gone.
“There is going to be a big gap in our lives now, but your legacy and influence will remain undiminished on everyone.”
In a statement issued after the inquest, EKHUFT chief executive Tracey Fletcher told KentOnline: “We accept and are deeply sorry for the failings in Megan’s care.
“We have made significant improvements to the way we respond when a patient discharges themselves, including working more closely with patients around their understanding of self-discharge and reviewing all patients who reattend the emergency department within 48 hours for the same complaint and working with partners to provide more support in the community.”
EKHUFT has been approached for further comment.
