A coroner has found that neglect contributed to the death of a “fit and healthy” 20-year-old who was repeatedly misdiagnosed in the days before she died.
Libby Instone, from the UK, died in August 2023 after suffering an infarction of her small intestine. An inquest heard she had visited an urgent care centre three times in just over 24 hours, where she was told she had gastroenteritis, despite being severely unwell and vomiting for days.
Coroner Clare Bailey said the Newcastle University law student, who had ambitions of becoming a barrister, died after a blockage in her intestine led to a cardiac arrest.
Her mother, Susan Instone, told the inquest her daughter had returned from a trip to London on 16 August before becoming seriously ill.
Two days later, after Libby continued to retch and suffer extreme pain, her mother called emergency services and took her to North Tees Hospital’s urgent care centre. She was prescribed anti-nausea medication, but was not physically examined, the court heard.
Although she was sent home, her condition did not improve and her family returned to the centre later that evening. A doctor again diagnosed gastroenteritis and she was placed on a saline drip before being discharged at about 1.30am.
Soon after leaving, Libby vomited “black liquid” in the car park. Her parents brought her back later that afternoon, describing her as “totally exhausted and very weak”.
After speaking with staff, the family decided to go to the emergency department, where they waited around nine hours before she was seen. She was given fluids, pain relief and anti-sickness medication before being admitted to a ward.
The following day, her parents claimed staff appeared distracted, watching a Women’s World Cup penalty shoot-out on television.
Libby was later discharged, but her condition continued to deteriorate.
“She said she was scared and asked if she was going to die,” her mother told the inquest, as reported by the BBC. “I laughed and told her not to be daft.”
Minutes later, Libby collapsed. Paramedics were called and she was rushed to hospital, but she could not be saved.
In emotional evidence, her mother told the court: “A female member of staff then came up to me and told me that they had just thought she was a time-waster.
“She was a nurse. We had just lost Libby and I didn’t know what was going on.”
She said the family were initially told nothing could have been done to save her daughter, only learning the full circumstances months later.
“My daughter’s last few days of life were horrendous,” she told the inquest. “Libby was in constant agony, she was scared.
“We went to hospital trusting in the people we believed would look after her but Libby was let down by doctors who were meant to take care of her.
“Libby was treated as an annoyance, a time-waster and was never shown any compassion.”
An independent medical expert found Libby had not opened her bowels for several days, something that should have raised concerns she did not have gastroenteritis, which typically presents with diarrhoea.
The report concluded there were multiple missed opportunities to carry out scans, and that surgery could have successfully treated the blockage.
Dr Michael Stewart, group chief medical officer for North Tees and Hartlepool and South Tees Hospitals NHS Foundation Trusts, apologised to the family.
He told the inquest he offered “an unreserved and sincere apology for the missed opportunities in Libby’s care”, adding there had been a “degree of confirmation bias” in sticking with the gastroenteritis diagnosis.
Coroner Clare Bailey found the hospital’s “failure to consider anything other than gastroenteritis” amounted to “gross failures in her care”.
She said this was worsened by infrequent checks, poor recording of symptoms and a lack of basic care.
“Libby’s death was contributed to by neglect,” she concluded.
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