A young disabled woman died after a hospital failed to administer antibiotics after surgery, a new report has detailed. 

Kate O'Donnell from Marske, died on March 23, 2022, at James Cook University Hospital, only days after having surgery. She had contracted sepsis after undergoing an appendectomy (appendix removal) and a stoma removal. 

The 23-year-old had a long medical history, including a germ-cell brain tumour reoccurring throughout her childhood. Treatment with chemotherapy and radiotherapy left Kate paralysed below the waist, and gave her chronic nerve pain. 

Now, a damning coroner's report into Kate's death said that faults in care, such as incorrect prescriptions, poor planning, incomplete records, and "understated" pain scores, could have been avoided.  

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An inquest ruled that failure to give the young paralysed woman preventative antibiotics contributed to her death, an inquest heard.

In a prevention of deaths report, the coroner warned that action can and should be taken to stop people dying in future. 

Kate was admitted for scheduled surgery on March 16, 2022, but there were issues in the run up to her operating - including notes being "mislaid", uncertainty about which surgeons would be involved, and what the surgery would involve. 

Before undergoing surgery, she undertook a urine test that showed a resistance to ciprofloxacin, a medication for serious infections. An audit of digital medical records showed that her consultant urologist did not check these test results before the operation. 

In line with his "usual practise", the consultant administered prophylactic gentamicin at the start of the procedure and provided ciprofloxacin post procedure. The latter was ineffective as Kate was resistant to that medication. 

The senior coroner for Teesside and Hartlepool, Clare Bailey, said: "I determined that the surgeon was unaware of the classification of surgeries and didn’t know that surgery could be clean-contaminated.

"He did not know of the SIGN guidelines and that prophylactic antibiotics were highly recommended for that type of gastrointestinal surgery. I held that a member of the colorectal team should have assisted with the operation."

The coroner also concluded that Kate should not have been discharged when she was - as she had vomited, was explaining high levels of pain, and a doctor had not assessed her.

But the family were allowed to leave the hospital and were not briefed on sepsis, or what to do if Kate deteriorated. 

One of the hospital's clinical directors accepted that "more should have been done to check on Kate's sodium before she was discharged", and that "a nurse should have contacted a doctor about pain scores."

The coroner said: "Kate should not have been discharged without a thorough further medical assessment which had been prompted by accurate medical recordings. The family should not have left hospital without information on sepsis or what to do if Kate was to deteriorate.

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"In the days following discharge Kate vomited daily, most days suffering several bouts of vomiting. I accepted that the Ciprofloxacin probably suppressed the sepsis that Kate was battling post-surgery."
 
Kate deteriorated and ultimately was taken to James Cook University Hospital on the morning of March 23, 2022. She passed away shortly after her arrival.

James Cook Hospital in Middlesbrough must give the coroner details of action taken, or proposed to be taken, by March 16, 2024.