Coroner to warn schools of sepsis risk as parents plan further action
THE heartbroken parents of a teenager who died on a school trip abroad have said they will be pursuing civil action in the High Court.
Ana Uglow, 17, a student at Bristol Grammar School, collapsed in her New York hotel room and was pronounced dead at Mount Sinai West hospital on December 19, 2019.
Speaking after the inquest into her death, Ana’s parents David and Natalia Uglow said there was “ample opportunity to get medical help that would have prevented her death”.
They said: “The right place now to determine these issues is a civil action in the High Court, and we intend to pursue this now the inquest has concluded.”
Maria Voisin, senior coroner for Avon, found Ana had died from bronchopneumonia and sepsis complicating an influenza upper respiratory infection.
She reached a narrative conclusion following a five-day inquest and said she could not find any “gross failings” by the teachers on the trip.
She said she will write to all schools to raise awareness of sepsis following Ana’s death.
Ana was on a school history trip to Washington, Philadelphia and New York. Her parents said Ana told teachers she thought she had a chest infection and asked to see a doctor two days before her death, but this was “refused”.
The two teachers, Rory Hambly and Ellice Clare, have insisted Ana only complained of feeling tired and having a cold, and did not directly ask to see a doctor.
Ms Voisin said Bristol Grammar School now included sepsis awareness within its first aid training for staff.
She said: “This case clearly demonstrates how awful this condition is and how tragic the consequences can be if left untreated.
“I will be making a report to raise sepsis awareness in all schools.”
Ms Voisin concluded: “It is clear that Ana was ill throughout the entirety of the trip. She had influenza and pneumonia with group A streptococcus.
“Equally, it is clear that her body was able to compensate.
“The extent of the severity of her illness wasn’t apparent to those around her.”
She said she had to take account of how Ana appeared during the trip, adding: “I cannot find any gross failings by the teachers in this case”.
Ms Voisin said Ana, of Redland, was a “fit and healthy” 17-yearold who developed influenza on the evening of December 11.
Ana was off school on December 12-13 but felt well enough to go on the trip, leaving for Washington early on December 14.
Her teachers reported she was homesick on the coach to the airport but had “no concerns about her health”, the coroner said.
On December 15, Ana “participated in the day’s activities” on the trip and neither teacher was worried about her health.
The following day, Ana asked if she could stay at the hotel as she was “tired”, and was seen resting on a bench at the National Museum of African American History and Culture.
During the train journey from Washington to Philadelphia, Ana told her mother she was worried she had a chest infection, felt much worse, had a fever and cough and felt out of breath.
Her mother told her to ask the teachers if she could see a doctor. Both Mr Hambly and Ms Clare recalled how Ana raised the possibility of going to a doctor with them but did not directly request to do so.
That evening, Ana was taken to a pharmacy in New York and told her teachers she had a “blocked nose”. They suggested she buy nasal decongestant and cough syrup.
On December 18, Ana again asked her teachers if she could stay at the hotel as she was “tired” and had a cold. They encouraged her to come on a walking tour and said she could rest in the afternoon if needed.
Ana went shopping with a friend that afternoon before going to the Empire State Building, where she was seen coughing and retching over a bin.
Mr Hambly took Ana, who he described as “tired and full of cold”, back to the hotel and plans were made for him to stay there with her the following day if she did not improve.
Ana awoke Mr Hambly at 6.15am on December 19, telling him she felt ill.
Mr Hambly told the inquest Ana was “walking and talking normally”, while Mrs Clare said she felt Ana’s pulse and “calmed her down” with breathing exercises.
At 7.30am, two friends Ana was sharing a hotel room awoke to find she had suffered a nose bleed. They reported how she was pale, struggling to form words and making noises as if in pain.
Mr Hambly told the inquest he discussed with Ana her seeing a doctor that day but a short time later the teenager collapsed in front of him. He called 911 at 8.15am and began performing CPR. Paramedics arrived at the hotel at 8.26am and took Ana to hospital, where she was pronounced dead at 10am.
Ms Voisin said Ana had influenza on December 11, which developed into pneumonia between December 16 to 17 and sepsis between December 18 to 19.
❝ This case clearly demonstrates how awful this condition is and how tragic the consequences can be if left untreated.
Coroner Maria Voisin