Mum whose broken leg was not spotted by doctors died after ‘gross failings’ in her care
A HALF-MARATHON-RUNNING mum died after “gross failings and neglect” when her broken leg went undiagnosed in an NHS hospital, a coroner ruled yesterday.
Mum-of-two Sarah-Jayne Roche, 39, died as she lay in theatre to fix her “snapped” thigh bone after collapsing during last year’s Cardiff Half Marathon.
An inquest heard she was sent home from hospital three times with no X-ray – and died during surgery at the Royal Glamorgan Hospital in Llantrisant after developing deep vein thrombosis (DVT).
Acting senior coroner Graeme Hughes said there were three “red flag opportunities” missed to X-ray Mrs Roche – leading to a “gross failure” on the part of clinicians.
Mr Hughes listed 14 findings in the inquest and found that had there been an X-ray, the operation to fix her leg would have taken place a week earlier.
He said: “I am satisfied, had she been X-rayed on October 7, 8 or 12, on the balance of probabilities she would have survived and not died on October 19.”
The coroner said there was a failure in Mrs Roche’s care when all three hospital appointments were “considered cumulatively”.
He said: “They do amount to a sufficient level of fault. There were three proximate red flag opportunities to procure an X-ray.”
The coroner added there was a “serious underestimation” of Mrs Roche’s condition and the fact her fracture was rare was “irrelevant.”
Mr Hughes recorded a narrative conclusion at the inquest in Pontypridd.
He said: “Whilst undergoing surgery to fix a fractured femur at the Royal Glamorgan Hospital on October 19, 2018, Sarah-Jayne Roche developed pulmonary thromboembolism as a consequence of an undetected and undiagnosed deep vein thrombosis.
“She went into cardiac arrest and despite extensive resuscitation attempts died at 7pm that evening.”
He added there was a “gross failure on the part of clinicians” to develop a correct diagnoses – contributing to the development of DVT, pulmonary thromboembolism and her death.
The coroner also said there was “conflicting” evidence from Dr Tim Manfield who saw Mrs Roche on October 12, and her mum Patricia Newman.
Mrs Newman claimed the doctor did not physically examine her daughter’s leg despite being told it was “freezing cold”.
Dr Manfield said: “That is untrue, I remember feeling the knee, thigh and hamstring and pulling on the lower leg.”
Dr Manfield also told the inquest he ordered an ultrasound but the paperwork was never found.
The inquest heard school worker Sarah-Jayne, of Beddau, near Pontypridd, was running the Cardiff Half Marathon as a goal to do before she was 40.
The mum of two sons, aged 12 and eight, was running to raise money for Parkinson’s disease after her father Alan was diagnosed with the illness.
At the seven-mile point in the race with her husband Steven, 42, she felt “a shooting pain up her leg” and came to a halt.
She visited hospital on three occasions where she was given painkillers and told to apply ice – but was never sent for an X-ray.
The inquest heard she finally went to A&E on October 16 and was admitted when doctors spotted her leg was “badly deformed”.
Consultant orthopaedic surgeon Dr Daniel Lewis said it was “the most traumatic day of his professional career” when Sarah-Jayne died during surgery.
The inquest heard her “snapped” femur bone was due to be nailed back together when a blood clot entered her lungs in theatre on October 19.
Her medical cause of death was pulmonary thromboembolism with deep vein thrombosis and a fractured femur.