Student treated as 'time-waster' before death
SuppliedNeglect contributed to the death of a normally fit and healthy law student, a coroner has found.
Libby Instone, 20, from Billingham, Teesside, was told she had gastroenteritis during three visits to an urgent care centre in just over 24 hours and had been vomiting for days when she collapsed in August 2023.
Teesside coroner Clare Bailey was told the Newcastle University student, who hoped to become a barrister, died as a result of an infarction of her small intestine.
Her mother Susan Instone said a member of staff told her "they had just thought she was a time-waster". The local health trust offered "an unreserved and sincere apology".
In a statement, the 57-year-old told the inquest her daughter had returned from a trip to London with her boyfriend on 16 August when she began vomiting and was in extreme pain.
With Libby continuing to retch, she rang 111 on 18 August and took her to North Tees Hospital Urgent Care Centre (UCC) where she was prescribed anti-sickness drugs but was not examined, she said.
Her daughter, who she said was usually fit and energetic, was sent home, but her family took her back to the UCC that evening. A doctor said Libby had gastroenteritis and she was put on a saline drip.
HandoutInstone, who attended the inquest with Libby's father Ian, said her daughter was again sent home at 01:30 BST, only for her to vomit "black liquid" in the car park.
Her parents took her back to the UCC at 14:30 BST as she was "totally exhausted and very weak", her mother said.
After discussions with a member of staff, the family decided to take Libby to an accident and emergency unit and started the waiting process again.
Her mother said they waited for about nine hours to be seen, before a nurse put her on a drip and she was given painkillers and anti-sickness medication.
Libby was admitted to a ward and her parents visited the next day, but claimed staff were pre-occupied watching a penalty shoot-out in the Women's World Cup on TV.
Later, Libby was allowed to go home but her mother said her daughter continued to feel unwell.
"She said she was scared and asked if she was going to die," she said. "I laughed and told her not to be daft."
Minutes later, Libby collapsed and paramedics were called. She was taken to hospital but could not be saved, the inquest heard.
Handout"A female member of staff then came up to me and told me that they had just thought she was a time-waster," Instone said.
"She was a nurse. We had just lost Libby and I didn't know what was going on."
In the days after her death, Instone said the family were told by the hospital that Libby could not have been saved, and only found out the truth six months later.
"My daughter's last few days of life were horrendous," she said. "Libby was in constant agony, she was scared.
"We went to hospital trusting in the people we believed would look after her but Libby was let down by doctors who were meant to take care of her.
"Libby was treated as an annoyance, a time-waster and was never shown any compassion."
'Missed opportunities'
An independent medical expert, instructed by the coroner, found Libby had not been able to open her bowels for some days and that should have aroused suspicion among medics that she did not have gastroenteritis, as a usual symptom was diarrhoea.
The report found multiple chances were missed for a scan of her stomach to be undertaken and an operation could have successfully treated her blocked intestine.
Dr Michael Stewart, group chief medical officer for North Tees and Hartlepool and South Tees Hospitals NHS Foundation Trusts, told the inquest he offered "an unreserved and sincere apology for the missed opportunities in Libby's care".
He said there had been a "degree of confirmation bias" regarding the unchanging diagnosis of gastroenteritis.
The coroner said the hospital's "failure to consider anything other than gastroenteritis" constituted "gross failures in her care".
This was compounded by infrequent physical checks, incorrect recording of vomiting and a lack of basic care, Bailey said.
The coroner said Libby had suffered a cardiac arrest as a result of the blockage in her intestine.
"Libby's death was contributed to by neglect," she said.
Bailey accepted that procedures have improved at the trust.
