Coroner Says 'Utterly Indefensible' Decisions at West Suffolk Hospital Contributed to 28‑Year‑Old's Sepsis Death

A coroner has concluded that a series of failures at West Suffolk Hospital "directly contributed" to the death of 28‑year‑old Hannah West and described some clinical decisions as "utterly indefensible". Coroner Darren Stewart reported two doctors involved in her care to the General Medical Council (GMC) before recording a narrative conclusion at the inquest.

Inquest Findings

Ms West arrived at West Suffolk Hospital in Bury St Edmunds shortly before 01:00 GMT on 18 January 2024 after sustaining two self‑inflicted abdominal wounds. A&E notes recorded that the object that pierced her abdomen had gone in clean but "come out dirty," a detail that suggested possible bowel contamination or perforation.

Despite this warning sign, the information was not escalated promptly to the on‑call surgical consultant. Clinicians initially agreed a conservative plan of observation, antibiotics and intravenous fluids rather than immediate surgery.

Timeline and Clinical Escalation

Over the next several hours Ms West's condition deteriorated. She was prepared for surgery at about 08:00, but the laparotomy did not begin until 11:27. Expert witness and consultant general surgeon Mr Omar Khan told the inquest it was "utterly indefensible" to delay operative management and said that, on the balance of probability, an emergency laparotomy begun by 08:00 would likely have given Hannah a chance to survive.

Staff had reported gastric fluid leakage and a CT scan showed fluid or gas in the abdomen, but escalation to immediate surgery did not occur. By the time the operation was completed Ms West was showing signs of septic shock; she died the following day.

Accountability

Senior surgeon Dr Akshay Bavikatte Prasannakumar decided to perform a CT scan rather than take Ms West straight to theatre, despite testimony that faecal contamination had been observed on the penetrating object. Coroner Darren Stewart told the court that Dr Prasannakumar had given "inaccuracies and half‑truths intended to present a particular narrative that did not present him in the worst possible light." The coroner confirmed he would report Dr Prasannakumar and one other doctor involved in Ms West's care to the GMC.

Mental Health Care Concerns

The inquest also examined the care Ms West received from Norfolk and Suffolk NHS Foundation Trust for Emotionally Unstable Personality Disorder. Evidence showed her care plan had not been updated, no safety plan was in place, and her consultant psychiatrist was absent from multiple meetings about her treatment. In the days before admission she had contacted 111 and an out‑of‑hours community service reporting that she was hearing voices urging self‑harm; on one occasion the on‑call mental health team reportedly told her to "watch television" while she considered harming herself.

In a statement read in court, Hannah's family described her as someone who "loved with her whole heart" and said she was central to the childhoods of every niece and nephew she had. They said they were devastated by her loss.

Reaction and Next Steps

Meg George, the family's solicitor, said the coroner's conclusions left "no doubt about the scale of multiple failures" by both trusts and that, in relation to West Suffolk Hospital, the failures amounted to neglect and directly contributed to Hannah's death. West Suffolk NHS Foundation Trust has been approached for comment. The coroner's decision to report two doctors to the GMC may prompt further professional investigations.

If you have been affected by the issues raised in this article and need support, organisations such as the Samaritans and local NHS mental health services can offer help.