Darren Snow instructed by Leigh Nagler, Royal College of Nursing Head Office Legal team, represented nurse CD in the inquest concerning the death of Lauren Sandell, an 18 year old university student, who died from the meningitis virus within weeks of arriving at university in October 2016.
The inquest revealed that she had missed having the Men ACWY vaccine through her school and GP. Had it been given Lauren would have been unlikely to have died. Nurse CD was the practice nurse at the family’s GP surgery, working 3 days a week. Alongside clinical duties, CD had taken on responsibility for the surgery’s clinical administration tasks and giving all vaccines including the Men ACWY vaccine at the surgery.
In 2015 the local authority took the decision that teenagers in the 16 – 18 age range should be vaccinated by their GPs rather than at school. In 2016 under an NHS catch up programme the Men ACWY was to be given to all teenagers turning 18 through GPs where they had missed the vaccine at school. There was a particular focus on those turning 18 going off to university where the social environment is so susceptible to the spread of meningitis. Lauren had not had the vaccine at school. Regrettably due to the practice workload and poor systems in place at the time Lauren was not identified for the vaccine so not contacted by her GP practice to come in for it. The family only became aware of the vaccine when Lauren’s mother attended the surgery in respect of an unrelated matter days before Lauren was due to leave for university.
An appointment was made with the GP surgery for the vaccine to be given to Lauren at the end of October when she was due to return for half term. The evidence indicated that neither the school or university had notified Lauren of the need for this vaccine before attending university.
The GP practice has changed systems and practices since Laurens death and was now outperforming many other practices with its delivery of the vaccine to 18 – 25-year olds. The inquest revealed a continuing lack of a continuity between GP practices generally in their approach to providing this vaccine and the continued low take up rates by patients due the vaccine. The inquest also identified the vulnerability of registered nurses working as practice nurses managing significant workloads, often employed part-time and where a GP practice may delegate responsibilities to its practice nurse for vaccine programmes with little insight or appreciation of the workload involved.
The Coroner, Ms Nadia Persaud will be preparing a Regulation 28 Preventing Future Deaths Report focused upon the need to educate GP practices, to ensure a joined-up approach to publicity, education, systems, communication and delivery of the vaccine service. Lauren’s mother continues to work on raising awareness nationally with schools about the importance of vaccination.
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