A coroner is to write to all schools to raise awareness of sepsis after a teenager died with the condition during a school trip to New York.
Ana Uglow, 17, a student at Bristol Grammar School, collapsed in her hotel room and was pronounced dead at Mount Sinai West hospital on December 19 2019.
Avon Coroner’s Court has heard that Ana, a senior prefect who aspired to attend Oxford University, was on a school history trip to Washington, Philadelphia and New York at the time.
Her parents, David and Natalia Uglow, said Ana told teachers she thought she had a chest infection and asked to see a doctor two days before her death – but this was “refused”.
The two teachers, Rory Hambly and Ellice Clare, have insisted that Ana only complained of feeling tired and having a cold, and did not directly ask to see a doctor.
Maria Voisin, senior coroner for Avon, said Ana had died from bronchopneumonia and sepsis complicating an influenza upper respiratory infection.
She reached a narrative conclusion following a five-day inquest and said she could not find any “gross failings” by the teachers on the trip.
Ms Voisin said Bristol Grammar School now included sepsis awareness within its first aid training for staff.
“This case clearly demonstrates how awful this condition is and how tragic the consequences can be if left untreated,” the coroner said.
“I will be making a report to raise sepsis awareness in all schools.”
Ms Voisin said her report, to prevent future deaths, would be made at a “national level”.
She described how Ana, of Redland, Bristol, was a “fit and healthy” 17-year-old who developed influenza on the evening of December 11.
Ana was off school on December 12-13 but felt well enough to go on the trip, leaving for Washington early on December 14.
Her teachers reported that she was homesick on the coach to the airport but they had “no concerns about her health”, the coroner said.
On December 15, Ana “participated in the day’s activities” on the trip and neither teacher was worried about her health.
The following day, Ana asked if she could stay at the hotel as she was “tired”, and was seen resting on a bench at the National Museum of African American History and Culture.
During the train journey from Washington to Philadelphia, Ana told her mother she was worried she had a chest infection, felt much worse, had a fever and cough and felt out of breath.
Her mother told her to ask the teachers if she could see a doctor. Both Mr Hambly and Ms Clare recalled how Ana raised the possibility of going to a doctor with them but did not directly request to do so.
That evening, Ana was taken to a pharmacy in New York and told her teachers she had a “blocked nose”. They suggested she buy nasal decongestant and cough syrup.
On December 18, Ana again asked her teachers if she could stay at the hotel as she was “tired” and had a cold. They encouraged her to come on a walking tour and said she could rest in the afternoon if needed.
Ana went shopping with a friend that afternoon before going to the Empire State Building, where she was seen coughing and retching over a bin.
Mr Hambly took Ana, who he described as “tired and full of cold”, back to the hotel and plans were made for him to stay there with her the following day if she did not improve.
Ana awoke Mr Hambly at 6.15am on December 19, telling him she “didn’t feel great, she felt stressed and anxious and her heart was racing”, she had a sore back and had not slept well, the coroner said.
Mr Hambly told the inquest Ana was “walking and talking normally”, while Mrs Clare said she felt Ana’s pulse and “calmed her down” with breathing exercises.
They gave her water, a banana and some painkillers, and walked her back to her hotel room to sleep.
At 7.30am, two friends Ana was sharing a hotel room awoke to find she had suffered a nose bleed. They reported how she was pale, struggling to form words and making noises as if in pain.
Ana told her friends “I think I’m going mad” and “I can’t feel anything” before asking Mr Hambly, who was brought to the room, “Why is this happening to me?”.
Mr Hambly told the inquest Ana was “lucid and responsive” and he discussed her seeing a doctor that day with Mrs Clare, but a short time later the teenager collapsed in front of him.
He called 911 at 8.15am and began performing CPR. Paramedics arrived at the hotel at 8.26am and took Ana to hospital, where she was pronounced dead at 10am.
Ms Voisin said Ana had influenza on December 11, which developed into pneumonia between December 16 to 17 and sepsis between December 18 to 19.
Two medical experts, Dr Chris Danbury, a consultant in intensive care medicine, and Professor Andrew Lever, an expert in infectious diseases, said Ana would have survived if given oral antibiotics on either December 17 or 18.
Dr Nelly Ninis, a consultant general paediatrician, said Ana would have needed to be admitted to intensive care at least six hours before her collapse to “reverse” what happened.
Prof Lever said it is likely that Ana would have survived her cardiac arrest at 8.15am if a paramedic or doctor had been present, administered appropriate treatment and taken her to hospital.
However, Dr Ninis said this “would not have made any difference”, the coroner said.
Ms Voisin concluded: “It is clear that Ana was ill throughout the entirety of the trip. She had influenza and pneumonia with group A streptococcus.
“Equally, it is clear that her body was able to compensate. The extent of the severity of her illness wasn’t apparent to those around her.”
She said she had to take account of how Ana appeared during the trip, adding: “I cannot find any gross failings by the teachers in this case”.
Speaking after the inquest, Ana’s parents David and Natalia Uglow said there was “ample opportunity to get medical help that would have prevented her death”.
“The right place now to determine these issues is a civil action in the High Court, and we intend to pursue this now the inquest has concluded,” they said.
Jaideep Barot, the headteacher of Bristol Grammar School, said Ana’s death had “devastated” the school and offered his “continued condolences” to her family and friends.
“Ana was a very kind, very popular and well-liked member of our school and she was one of our senior prefects,” he said.
Mr Barot added that the school would assist the coroner in raising awareness of sepsis among schools across the UK.