The tragic death of a much-loved primary school teacher with a “beautiful soul” could have been avoided, hospital bosses have admitted.
Megan Williams died suddenly at her home in School Road, Acrise, near Folkestone, days after she first suffered severe abdominal pain.
Doctors at William Harvey Hospital in Ashford thought she had gastritis, but she actually had an intestinal obstruction caused by a previous appendectomy.
It was the undiagnosed problem that ultimately led to the 40-year-old’s death, with devastated colleagues at Cherryton Primary School describing him as “simply the best of us all”.
The chief executive of East Kent Hospitals Trust has since said she was “deeply sorry” for the lapse in Ms Williams’ care.
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Maidstone County Council launched an inquest into the mother’s death on Tuesday.
The coroner heard Ms Williams first fell ill on the evening of May 1 last year. At 3am the next morning, she suffered from violent vomiting and was taken by ambulance to William Harvey.
Her pain levels fluctuated widely during her time in the hospital, ranging from a 5 to a 10 on a scale used by medical professionals.
She was discharged from hospital the same day and diagnosed with gastritis – inflammation of the stomach lining.
Ms Williams fell ill again while leaving hospital at about 4pm. However, the incident was not recorded in the medical files – clinicians later said that had this been known at the time, their approach to treatment would have changed.
Two days later she was returned to hospital and had to be carried by ambulance crews as she continued to struggle with abdominal pain.
Given his recent discharge from hospital, the teacher should have been examined by a team of specialists, but this did not happen.
“The trust accepted that there were lapses in Meghan’s care that amounted to a breach of duty and that without these lapses, Meghan’s death could have been avoided…”
It is believed she left at 1am on May 5 and was not seen before discharging herself. It’s unclear whether she was fully aware of the dangers of doing so.
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Two hours later, Ms Williams felt unwell at home and experienced difficulty breathing at 7.30am. Thirty minutes later she suddenly sat up and declared that she needed to be sick again.
At this time, she had fallen to the ground and lost consciousness. Her family and ambulance crews spent more than two hours trying to resuscitate her before she was pronounced dead at 9.58am.
An autopsy found Ms Williams died of aspiration pneumonia, small bowel obstruction and strangulating internal hernia caused by intra-abdominal surgical band adhesions.
Aspiration pneumonia is a lung infection that can be caused by inhaling saliva, food, or stomach contents.
The coroner reviewed a range of evidence relating to Ms Williams’ death before reaching his conclusion, including a letter signed by the trust’s chief executive Tracey Fletcher which was handed to representatives representing the trust. The family’s lawyer.
The document, signed on March 17 this year, acknowledged that following an investigation Ms Williams’ death could have been avoided.
Ms Fletcher wrote: “The trust accepted that there were lapses in Meghan’s care which amounted to a breach of duty and that without these lapses Meghan’s death could have been avoided.”
“There is no doubt that everyone who was caring for Meghan thought they were doing what was best for her at the time, but in hindsight it is clear that we did something wrong in her care.
“For that, I’m deeply sorry.”
The inquest will also look into how the opportunity to give Ms Williams a CT scan was missed. However, it is unclear whether this will necessarily help, and this is considered a clinical decision.
Megan’s fluctuations in pain levels were related to parts of her intestine becoming stuck in scar tissue, repeatedly detaching and reattaching.
Coroner James Dillon concluded there was a lack of understanding among clinicians about the “pathway” of patients with acute abdominal pain.
He said Ms Williams should be returned to the care of the discharge team, adding there was no evidence she signed any discharge documents.
Mr Dillon issued a narrative conclusion while delaying a decision on whether to commission a report that could help prevent further deaths.
“There will be a big gap in our lives now, but your legacy and impact will be the same for everyone…”
He said: “If I are reporting a narrative conclusion, then I must adhere to the principles of brief, neutral, factual presentation and should not express any judgment or opinion.
“I have not been advised by anyone interested to make a finding of negligence, nor do I think it would be appropriate to do so.
“Megan Williams passed away at her home on May 5, 2022.
“She died of undiagnosed small bowel obstruction, apparently caused by band adhesions from a previous intra-abdominal surgery.
“She went to hospital twice, both times by ambulance – on May 2, she was discharged with suspected gastritis, and on May 4, she was discharged on her own in the early hours of the next morning and died after returning home.”
Ms Williams was born in Ashford on January 5, 1982. She graduated with a first class honors from the University of Bristol in 2003 and began traveling throughout Europe.
A charity marathon runner, she continued her studies at Canterbury Christ Church University, qualified as a teacher in 2013 and gave birth to her son in 2019.
She also helped clean up the environment after the 2005 Hurricane Katrina disaster in the United States.
A colleague named Jessie wrote on an online tribute page: “She was the kindest, most compassionate person I have ever had the privilege to call a colleague and friend.
“It’s amazing to watch Megan teach. The whole room lights up, adults and children alike are captivated by her enthusiasm and love of learning.
“It’s rare and beautiful to find qualities like this in a teacher, and Megan has them!”
“The world would be a poorer place without Meghan. “I was privileged to have known her and she will be forever missed. “
Ian, Claire and Angie Hotham also paid tribute, saying Ms Williams “left such a void in the lives of everyone who knew you”.
They added: “Your warm, caring, bubbly and sparkling personality was intertwined with your love for your family and friends.
“Your zest for life is evident and the passion with which you speak inspires and engages those around you.”
Meghan’s brother Glynn Williams said: “My beautiful, amazing sister. It’s so hard to accept your passing.
“There will be a big gap in our lives right now, but your legacy and impact will remain undiminished for everyone.”
In a statement following the investigation, East Kent Hospital chief executive Tracey Fletcher told KentOnline: “We accept there were errors in Meghan’s care and are deeply sorry.
“We have made significant improvements to how we respond to patients when they self-discharge, including working more closely with patients around their understanding of self-discharge, reviewing all patients who return to the emergency department within 48 hours with the same complaint, and working with Partners work together to provide additional support to the community.”