A teenager died a fortnight after having an abortion because of delays in giving her a vital blood transfusion.
The inquest in Bristol heard that A-level student Manon Jones, 18, from Caernarfon began to bleed after the operation and admitted herself to hospital, where she died.
A doctor told the inquest the Southmead Hospital ward in Bristol had been busy and "things could have been different" in 2005 when Manon died. Coroner Brian Whitehouse said that this was one of the saddest cases he had to deal with in almost 40 years.
The inquest heard how Miss Jones, a Christian, had decided to terminate her pregnancy because she had concerns for her boyfriend and his family who were Muslims.
She went on holiday two weeks after the procedure despite medical advice not to. She cut short her break after feeling ill and returned to Bristol. Initial blood tests taken at the hospital, where she admitted herself, failed to alert medics to any serious condition. But more tests showed she needed a blood transfusion. However she was left waiting for the blood when another emergency broke out on the ward and her condition deteriorated resulting in her needing life support. Post-mortem tests showed she died of low haemoglobin levels and shock caused by "retained products of conception".
An emotional Dr Lucy Jackson, who treated her at the hospital, told the inquest: "If we hadn't been so busy, particularly with the other emergency, we would have had more time and things could have been different."
The inquest heard from Dr Richard Porter, a obstetrician at Royal United Hospital, in Bath, who did not treat Miss Jones. He said it was "wholly inadequate" to leave Miss Jones waiting for a blood transfusion for more than four hours. But, the doctor said, it was "hard not to conclude" Miss Jones would have survived had she not gone on holiday and attended hospital earlier.
Manon's mother Mrs Jones told the coroner she went to the hospital when her daughter was gravely ill and stayed at her bedside until a decision was made to turn off Miss Jones's life support machine.
The coroner said the death was not due to natural causes and verdict of misadventure would have been inappropriate. He said the narrative verdict was because Miss Jones died as a result of retained products of conception following the termination of a pregnancy. But he said there was no failure on the part of the NHS trust to provide basic medical care and it was certainly not a gross failure.
June 2008
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