Cricketer's daughter would've lived without delay

A student "would not have died" if her care and treatment had not been delayed, an inquest has found.

Bethan James, 21, from Cardiff, died on 8 February 2020 from a combination of sepsis, pneumonia and Crohn's disease, a post-mortem examination found.

South Wales coroner Patricia Morgan told an inquest in Pontypridd there were "a number of delays" to her care which "more than minimally contributed to Bethan's death."

Her parents, the former England and Glamorgan cricketer Steve James and her mother Jane described the inquest's conclusion as "heartbreaking".

The inquest focused on a three-week period between 27 January 2020 and 8 February 2020 when Ms James attended the University Hospital of Wales (UHW) "on numerous occasions".

She was diagnosed with pneumonia after being told she had Crohn's disease a few months before.

The court heard how she could not complete a course of antibiotics prescribed for the pneumonia because of side effects, including nausea and vomiting.

The coroner said Ms James was "reluctant" to go back to hospital after previous interactions with hospital staff.

During the inquest, her mother said she felt the staff had been "dismissive" of her daughter's condition.

Delivering her narrative conclusion, Ms Morgan said she had heard "conflicting opinions" on whether different and earlier treatment would have helped.

But she found that if paramedics had assessed the situation differently and alerted staff at the hospital sooner, "earlier treatment would have commenced", adding " on balance, she would not have died".

The coroner found sepsis was the immediate cause of death, with pneumonia as an underlying case and Crohn's disease as a likely contributory factor.

She explained Ms James died "as a result of pneumonia and sepsis" and there were "a number of delays which more than minimally contributed to Bethan's death".

The coroner said the ambulance crew failed to issue an alert letting the hospital know how sick Ms James was.

It would have meant her immediate admittance to the resuscitation area of the emergency department.

Ms Morgan said the failure resulted in the lead nurse for resuscitation being "unwilling" to become involved.

The coroner said she was "more persuaded" by evidence from an expert witness, Dr Chris Danbury.

"Dr Danbury expressed a strong view that the outcome would have been different for Bethan if she had been subject to a pre-alert and admitted into resus immediately," she said.

"Had this direct admission to resus and prompter recognition and treatment occurred, then cardiac arrest would not have occurred when it did, which would have enabled more time for other specialities to become involved in Bethan's care.

"On balance, I find that Bethan would not have died."

Speaking outside court, the family's barrister Richard Booth KC read a statement from the family, saying: "It is heartbreaking to know that with appropriate treatment, Bethan would not have died.

"At 21 and just finishing her journalism degree, our beautiful Bethan had a brilliant and full life ahead of her, but it was taken away by a catalogue of errors that could so easily have been avoided by better listening, understanding, recognition and actions by health care staff.

"Sepsis is still not spotted quickly enough, and this was a tragic example."

Her family also called on the Welsh government to follow England in giving patients and families a right to get a second opinion on care options.

Martha's rule was created after an inquest found that a change of care plan could have prevented 13-year-old Martha Mills' death from sepsis in 2021.

"We urge the Welsh government to implement Martha's Rule across the NHS in Wales so that needless and tragic deaths like Bethan's aren't repeated," they said.

The Welsh government said ensuring the voices of patients and their loved ones were heard was "paramount".

It added it was working with NHS organisations to identify the best patient and family-initiated escalation model and was implementing a patient safety plan which would help clinical staff identify deteriorating patients earlier.