Mum loses three limbs and kidney after L&D fails to spot sepsis

Magdalena Malec, aged 31, of Dunstable had both legs, her right arm and the fingers of her left hand amputated, as well as undergoing a kidney transplant after her treatment for an ectopic pregnancy went horribly wrong.

Polish-born Magdalena developed extensive limb ischaemia that became gangrenous as a result of medical staff at Luton & Dunstable University Hospital not recognising the classical warning signs for sepsis and failing to follow their own sepsis protocol.

Magdalena said: “My life before this happened was wonderful, with two fantastic children and a loving partner. We had got engaged and planned a happy future together. I was an active, cheerful and happy person. Most importantly, I was independent.

“Now my life is not a life, it is vegetation – a fight for life. I am not the kind of person who likes to ask for help but now I am forced to because I meet obstacles everywhere I turn. Every failure brings on difficult situations at home which are causing my relationship to fall apart.”

Magdalena continued: “Nothing will restore what I had. I will never paint my nails again, I will never make a ponytail for my daughter. The only thing I dream about is decent living conditions with my disability and prostheses which will allow me to live as normally as possible. Each hospital appointment brings sad memories.”

Asked how she feels about the way she was treated by the hospital, Magdalena said: “That hospital hurt me badly. I do not trust doctors and I am very sceptical about all medical appointments and diagnoses. I was waiting for six months for the amputation of my limbs, with stinking and decaying legs and arms. I probably will never trust any hospital again.”

Magdalena lives in Dunstable with her children Paulina, nine, and Severin, seven.

The couple had been trying for a child together and were delighted when Magdalena discovered she was pregnant in December 2014. But her joy turned into a nightmare after a scan at Luton & Dunstable University Hospital on 22 December indicated a miscarriage.

When Magdalena returned to the hospital for a blood test on Christmas Eve she told medical staff she was continuing to experience heavy bleeding and period-like cramps. Another scan was scheduled for 27 December.

However, in the early hours of 25 December, Magdalena was suffering unbearable pain in her stomach and Robert called an ambulance.

A junior doctor at the hospital’s emergency department sent her home with painkillers and anti-sickness pills, but her condition deteriorated.

She returned to the hospital later that day and was eventually admitted to the gynaecology ward in the afternoon of Christmas Day.

She was finally told that she had an ectopic pregnancy and needed urgent surgery to remove her left fallopian tube and the unviable foetus.

A serious incident investigation report by the hospital into Magdalena’s case said: “Prior to the anaesthetic she was noted to have a raised temperature, but due to the urgency of the clinical procedure she was considered clinically stable to undergo anaesthesia. She was given 1.2g of the antibiotic Co-amoxiclav.”

However, Magdalena’s temperature remained elevated while she was in the recovery room and back on the ward.

The report continued: “Eight hours after being given the anaesthetic she developed a generalised rash that was thought to be an allergic reaction to the Co-amoxiclav, which was stopped and the antibiotic prescription changed. Over the next eight hours Ms Malec became very unwell, developing septic shock, acute kidney injury and disseminated intravascular coagulation. She was transferred to the intensive therapy unit where she received multi-organ support.

“Ms Malec developed extensive limb ischaemia that progressed to gangrene. Ms Malec was transferred to a specialist hospital for the treatment of her kidney failure and she subsequently underwent radical surgery and amputation of both legs below the knee, her right arm below the elbow and the fingers of her left hand as a result of the limb ischaemia.”

The report concluded: “There were missed opportunities to recognise the progressive clinical deterioration of Ms Malec and act accordingly, including the timely administration of antibiotics.”

The hospital trust has apologised unreservedly for the distress caused to Magdalena and her family as well as for the impact the ordeal has had on her long term health and well-being.

Magdalena had to wait six months before undergoing an operation to amputate her limbs.

She said: “Prior to this my limb stumps were weeping and smelled awful and they had to be meticulously dressed every day. I recall one of my fingers literally dropping off my hand. I was in terrible pain and distress with my weeping wounds and totally dependent on others for help.”

Rehabilitation and prosthetic care has been provided by the Royal National Orthopaedic Hospital in Stanmore.

Magdalena said: “They are looking to provide and fit natural looking limbs once I have established full use of my stumps. I already have a ‘bionic’ right hand which I have been using since June 2017.”

In addition, she had to attend Luton & Dunstable University Hospital three times a week for dialysis, with each session lasting up to four hours.

She finally had a kidney transplant at Addenbrookes Hospital in Cambridge on 17 January 2017.

Magdalena no longer requires dialysis, but does need lifelong medication which increases the risk of infection.

Magdalena said: “From the very beginning everything was a big challenge for me. I would wake up and not know what I should do with myself. I have been left on my own, starting with re-learning how to walk, comb my hair, eat, and brush my teeth. I am learning how to live with pain. Going out and coping with the way people look at me is very difficult, and so is self-acceptance.

“My life is continual hospital appointments. I am susceptible to infections because my immune system is weakened by the medicines I take to support my kidneys. I am continuously asking for help and worrying about my children.”

Magdalena believes the impact of the calamity has also badly affected her children.

She said: “My children were watching their mother with black limbs from which pus was weeping. Later my children were seeing me without limbs. They experienced this as much as I did. I think that this had a huge impact on them psychologically.

“Even today my children are asking why their mother does not have arms and legs. I am doing everything I can to show my children that I am trying to function normally, but still situations happen when my son comes and says he wants me to be like I used to be.”

David Thomas, Clinical Negligence Partner at Simpson Millar solicitors, who acts for Ms Malec in her compensation claim, says: “The catastrophic chain of events which led to Magdalena’s near death and horrendous injuries were completely avoidable if the hospital Trust had followed its own sepsis protocol. There were a number of missed opportunities or ‘red flags’ which were not acted upon until it was too late. If diagnosed early enough, sepsis is easily treated with anti-biotics but despite recent awareness campaigns, mistakes such as this are still happening. It’s tragic.’’

A Luton and Dunstable University Hospital spokesperson, said: “The Trust wishes to convey its sincere apologies to Ms Malec and recognises that the care provided to her in 2014 fell below the standards that we strive for.

“The Trust undertook an investigation to examine what improvements could be put in place, and learnings from this were shared in order to prevent similar cases. Findings from the investigation were also shared with Ms Malec.

“We would like to assure Ms Malec, and all patients that we continue to work towards ensuring the quality of our services are maintained and improved where possible.

“As part of a national campaign to see earlier recognition and diagnosis of sepsis and timely administration of antibiotics, the Trust launched its ‘Sepsis Initiative’ in 2015.

“The Trust continues to build on the initiative to ensure that all patients presenting with, or developing signs of sepsis are screened and treated promptly ensuring that sepsis remains high on the Trust’s agenda.”