A coroner has ruled that neglect contributed to the death of a 20-year-old law student after multiple opportunities to identify and treat her condition were missed.
Libby Instone, described by her family as fit and healthy, died in August 2023 after making three visits to an urgent care center in just over 24 hours.
Following an inquest, Teesside Coroner Clare Bailey concluded that there had been “gross failures” in Libby’s care and found that several missed opportunities could have led to life-saving treatment.
It all began when Libby returned from a trip to London with her boyfriend. On August 16, 2023, she started experiencing severe abdominal pain and vomiting. Two days later, as her condition worsened, her mother, Susan Instone, called NHS 111 and took her daughter to North Tees Hospital’s Urgent Care Centre.
Libby Instone died after being dismissed by doctors
Speaking during the inquest, Susan said Libby was not examined during that first visit. Instead, she was prescribed anti-sickness medication and sent home.
When the symptoms persisted, the family returned to the urgent care center. A doctor diagnosed Libby with gastroenteritis, placed her on a saline drip, and then discharged her again. According to Susan, Libby vomited “black liquid” in the hospital parking lot.
A while later, Libby was “totally exhausted and very weak,” and was taken back to the urgent care center for a third time. Staff decided she should be transferred to the emergency department.
The inquest heard that Libby waited approximately nine hours before being seen. During that time, she received fluids, pain relief, and anti-sickness medication before eventually being admitted to a hospital ward.
Libby was later discharged, but her condition did not improve. Her parents said they had to physically carry her back to bed after returning home.
“She said she was scared and asked if she was going to die,” Susan told the inquest, according to LadBible. “I laughed and told her not to be daft.”
Moments later, Libby collapsed. She was quickly brought back to the hospital, but doctors were unable to save her.
“A female member of staff then came up to me and told me that they had just thought that she was a time-waster,” Susan said.
“She was a nurse. We had just lost Libby and I didn’t know what was going on.”
”My daughter’s last few days of life were horrendous”
Speaking about her daughter’s final days, Susan said: “My daughter’s last few days of life were horrendous.
“Libby was in constant agony, she was scared. We went 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.”
Theo Corbett, Libby’s boyfriend, also criticized the treatment Libby received.
“We we were trying to raise concerns that we had and tried to press as much as we could and how worried we were about Libby’s health,” he said during an appearance on Good Morning Britain.
“But no matter how much we pushed, no matter how much we pressed, it just felt like we couldn’t get anywhere.”
Theo described Libby as “beautiful, funny and fiercely intelligent” and told the inquest: “There was an enormous lack of decency, empathy and acknowledgment of Libby’s pain and illness at every attendance at hospital.”
She died as a result of an infarction of her small intestine
Medical evidence presented during the hearing found that Libby died after suffering an infarction of her small intestine and a cardiac arrest.
Delivering her findings, Coroner Clare Bailey said: “In Libby’s case, the failure to consider anything other than gastroenteritis despite Libby enduring four days of vomiting and agonizing abdominal pain constitutes gross failures in her care.
“There were missed opportunities to investigate the cause of her persistent abdominal pain and vomiting, and to provide life-saving treatment. Libby’s death was contributed to by neglect.”
Bailey noted that findings of neglect are reserved for cases involving gross failures to provide basic medical care to someone in a dependent position and said inquests are not intended to scrutinize every aspect of a patient’s treatment.
Dr. Michael Stewart, group chief medical officer for North Tees and Hartlepool and South Tees Hospitals NHS Foundation Trusts, issued an apology during the hearing.
The coroner acknowledged that procedures at the trust have since improved.
In a statement, 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.”
