A coroner has found neglect contributed to the death of a ‘fit and healthy’ Newcastle student
A Newcastle University student who died in agonising pain and was made to feel like a ‘time-waster’ by doctors before her death, a coroner has found
The coroner found that neglect contributed to the death of Libby Instone who was described by her family normally fit and energetic.
The 20-year-old from Billingham, Teesside, was told she had gastroenteritis during three visits to an urgent care centre in just over 24 hours. She had been vomiting for days when she finally collapsed and died in August 2023.
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Teesside Coroner Clare Bailey, sitting in Middlesbrough, was told the Newcastle University student, who hoped to become a barrister, died as a result of an infarction of her small intestine – finding that neglect contributed to Libby’s death.
She said neglect findings in inquests were limited to cases where there had been gross failure to provide basic medical attention to someone in a dependent position. She said it was not for inquests for criticise ‘every twist and turn’ of a patient’s treatment.
“In Libby’s case, the failure to consider anything other than gastroenteritis despite Libby enduring four days of vomiting and agonising abdominal pain constitutes gross failures in her care,” the coroner said.
This was compounded by infrequent physical checks, incorrect recording of vomiting and a lack of basic care, Ms Bailey said.
Recording a narrative conclusion, the coroner said Libby repeatedly visited North Tees Hospital Urgent Care Centre (UCC) in Stockton and was later admitted to hospital prior to being discharged home, later suffering a cardiac arrest.
“There were missed opportunities to investigate the cause of her persistent abdominal pain and vomiting, and to provide life-saving treatment,” she said. “Libby’s death was contributed to by neglect.”
Libby’s mother, Susan, 57, told the inquest in a statement that her daughter had returned from a trip to London with her boyfriend on Wednesday, August 16 when she began vomiting and was in extreme pain.
With Libby continuing to retch, the worried mother rang 111 on August 18 and took her exhausted daughter to UCC where she was prescribed anti-sickness drugs but was not examined, she said.
Her daughter, whom she said was usually fit and energetic, was sent home, but her concerned family took her back to the UCC that evening where a doctor said Libby had gastroenteritis and was put on a saline drip.
Mrs Instone, who attended the inquest with Libby’s father, Ian, said her daughter was again sent home at 1.30am on Saturday 19, only for her to vomit “black liquid” in the car park.
Her parents took her back to the UCC at 2.30pm that day as she was “totally exhausted and very weak”, her mother said. After discussion with a member of staff at the UCC, the family decided to take Libby to an accident and emergency unit and started the waiting process again.
Mrs Instone said they waited for around nine hours for Libby to be seen and a nurse put her on a drip and she was given painkillers and anti-sickness medication.
Libby was admitted to a ward that night and, the next day, her parents visited her but claimed staff were pre-occupied by watching a penalty shoot-out in the women’s World Cup on TV.
Mrs Instone said she visited Libby with her husband and they did not know where she was on the ward, saying in her statement: “All the staff were at the nurses’ station watching the Women’s World Cup final. It was penalties and all the nurses were stood around the telly.
“We asked if they could tell us where Libby was and someone said ‘you won’t get any sense out of them until this has ended’.”
Mrs Instone claimed it took 15 to 20 minutes before they got the staff’s attention, once the shoot-out had ended. Later that day, Libby was allowed to go home and she still felt so ill that she was carried back to bed after she had sat with her family for a while, her mother said.
Mrs Instone tried to feed her tomato soup, which she could not manage. Her mother said: “She said she was scared and asked if she was going to die. I laughed and told her not to be daft.”
Minutes later Libby collapsed and paramedics were called. Libby was taken to hospital but could not be saved, the inquest heard.
Mrs Instone said: “A female member of staff then came up to me and told me that they had just thought that she was a time-waster. She was a nurse.
“We had just lost Libby and I didn’t know what was going on.”
In the days after her death, the family said they were told by the hospital that Libby could not have been saved, and they only found out the truth six months later.
Mrs Instone said: “My daughter’s last few days of life were horrendous. Libby was in constant agony, she was scared.
“We were 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 that Libby had not been able to open her bowels for some days and that should have aroused suspicion among medics that she did not have gastroenteritis, as a usual symptom was diarrhoea.
The report found that multiple chances were missed for a scan of her stomach to be done, and that an operation could have successfully treated her blocked intestine.
Dr Michael Stewart, group chief medical officer for North Tees and Hartlepool and South Tees Hospitals NHS Foundation Trusts, told the inquest he offered “an unreserved and sincere apology for the missed opportunities in Libby’s care”.
He said there was a “degree of confirmation bias” regarding the unchanging diagnosis of gastroenteritis. The coroner accepted that procedures have improved at the trust.
A spokesperson from North Tees and Hartlepool NHS Foundation Trust said: “We are deeply saddened by the death of Libby Instone who was under our care.
“Our sincere condolences remain with her family, friends and loved ones during this difficult time. We accept the findings of the inquest today. We apologise to her family and continue to offer support to all involved.
“A thorough review of the circumstances surrounding this case has identified shortcomings in the care provided to Libby and her family.
“We are committed to learning from this tragic case and have implemented measures to strengthen processes to reduce the risk of similar incidents in the future”.

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