Kentish Express Ashford & District
Hospital’s fatal error over X-ray
A baby died from tuberculosis contracted from his father after medics failed to spot the disease in an X-ray at the William Harvey Hospital almost two years earlier.
Five-week-old Luchii Gavrilescu died at the QEQM hospital in Margate on December 6 last year from what was thought at the time to be sepsis caused by bronchiolitis.
But a post-mortem examination revealed the tot had in fact caught tuberculosis (TB).
His dad, Vlado Gavrilescu, had been unknowingly living with the infection, despite a lesion showing up on an X-ray of his lungs in March 2018 at the William Harvey in Ashford.
On January 15 - a day after his son’s funeral and almost two years after that first X-ray - he went back to hospital for a CT scan due to a persistent cough and weight loss and was given the shock diagnosis.
A report by the East Kent Hospitals Trust confirms the “significant delay” in diagnosis meant Mr Gavrilescu’s disease worsened.
It also led to Luchii and others – including his partner Laura Cooke, her two other children Archie and Macie, and family friends – being infected.
A separate investigation into the baby’s death states: “If the father’s TB had been detected and treated earlier, following the chest x-ray in 2018, Luchii’s death and transmission of infection to others could have been prevented.”
It was described as a “missed opportunity”.
Public Health England has now launched a probe looking at how far the “cluster” of TB infections has spread.
This includes, according to the family, screening of those at the maternity unit at the QEQM, where Mr Gavrilescu stayed when Luchii was born in October 2019.
The lesion on Mr Gavrilescu’s lungs could be seen on the chest X-ray taken two years ago at the William Harvey, where he was being treated following an assault, but it was not identified by the doctor at the time.
It has now been recommended all chest X-rays are formally reported on by the radiology department, who are experts in the field.
This probe is separate from another serious incident investigation being undertaken into Luchii’s death, which was described as “avoidable” by hospital chiefs.
Ms Cooke, 29, from Margate, had tried to get her baby treated in the week leading up to his death but was sent home twice, despite red flags pointing to a life-threatening condition.
Luchii was struggling to breathe, had mottled skin and wasn’t feeding properly. On his third visit to A&E, it was almost six hours before he was seen by a consultant, by which time it was too late to save his life.
A report revealed staff failed to recognise the severity of his symptoms and did not escalate the case to consultants, who were completely unaware of Luchii and his grave condition.
Ms Cooke said: “Words will never be enough because nothing will ever bring our beautiful little Luchii home.”
Mr Gavrilescu, who is from Romania, had been taken by ambulance to the William Harvey on March 7, 2018, after being abducted, beaten with a chain and stabbed in the head and shoulder. As part of his assessment, a chest X-ray and a CT scan of his head were taken.
In line with the hospital trust’s policy, plain chest X-ray films are not formally reported on by the radiology team, unless a clinician asks for specialist radiology opinion. Therefore it remained unreported.
Processes are now being put in place to ensure clinical staff receive and review X-rays.
A spokesman for East Kent Hospitals said the family continues to be supported and has been shown the initial report.
Dr Rachel Pudney, health protection consultant for Public Health England South East, says the organisation is working with the local specialist TB services and the hospital trust to identify any close contacts related to the case.
She added: “Those who are identified as close contacts are being made aware of the situation, and given advice on the signs and symptoms of TB along with the action they should take if they feel unwell with similar symptoms, as a precaution.”