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Harriet Gilchrist, instructed by Sammiya Ulhaq of Co-op Legal Services, represented the family of a 19 year old girl who died from the progression of natural disease contributed to by neglect on 25 January 2021.
In September 2020 the deceased first started to experience symptoms and contacted her GP reporting a sustained period of diarrhoea. Blood tests showed raised inflammatory markers and a gastroenterology referral was made. On 22 December 2020 the deceased again contacted her GP as she continued to feel unwell. Following a consultation with her GP, the deceased was referred to her local emergency department for further examination. The deceased was placed under the care of a Junior Doctor who arranged for further blood tests to be taken. The results were then examined by the Junior Doctor who failed to notice/appreciate an inflammatory marker reading, nearly 200 times outside the normal range. This reading was not including in the notes, nor was it communicated to the Registrar or Consultant on call. The deceased was discharged later that day with medication for diarrhoea.
When questioned, the Junior Doctor and representatives of the Trust accepted that if the inflammatory marker reading had been seen/appreciated then the treatment of the deceased would have been markedly different, namely she would have been admitted to hospital and undergone further tests which would have identified Inflammatory Bowel Disease and placed on antibiotics and steroid medication. It was the view of the Trust that it was likely she would have made a full recovery. When questioned on behalf of the family, the Trust accepted numerous failings, including that the failure to note/appreciate the high inflammatory marker reading contributed to the deceased’s death and that had the correct diagnosis been made and treatment started, she may have survived. On 21 January 2021, the deceased collapsed at home and was taken to her local emergency department by ambulance where emergency surgery was performed. During the operation the deceased was found to have sever colitis with a toxic megacolon which perforated during mobilisation. A subtotal colectomy was performed, and the abdomen left open. The deceased was transferred to ICU where, she died on 25 January 2021, aged 19. The medical cause of death, as recorded in the post-mortem was 1a) Septic shock, 1b) Toxic megacolon and 2) inflammatory Bowel Disease.
Coroner Nicholas Lane, on the balance of probabilities, found that if the deceased had been admitted to hospital on 22 December 2020, she would have been diagnosed with Inflammatory Bowel Disease and would not have been in the position she found herself in in January 2021. The Coroner found that alternative care and management would have prevented her death on 25 January 2021.
The Coroner invited submission on neglect. Submissions were made on behalf of the family and opposed by representatives of the Junior Doctor and the Trust. The Coroner found that the combination of failings, namely to failure to consider recent symptoms, the failure to consider Inflammatory Bowel Disease as a differential diagnoses and the failure to consider the high inflammatory marker reading did amount to a gross failure to provide basic medical care. The Coroner rejected the submissions made on behalf of the Trust and Junior Doctor and found that all elements of the test for neglect had been made out and that it was “safe and proper to include neglect in the conclusion”.
The Coroner concluded the cause of death as “progression of natural disease process, contributed to by neglect”.
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