Doctors’ ‘serious failings’ before death of teenager
A CORONER has told two out-ofhours telephone service doctors during an inquest into a teenager’s death that they were responsible for “serious failings”.
The inquest heard the family of Sammy-Jo Boyce, of Bonymaen, Swansea, made two calls to an out-ofhours GP service on the evening of Sunday, February 5, 2012, after the 19-year-old was confined to bed feeling unwell.
But Dr Nitin Gupta and Dr Tity Tiju, who took the calls at 6.28pm and 11.35pm respectively, failed to spot warning signs of diabetic ketoacidosis (DKA) which eventually became a major factor in her death, the inquest heard.
The situation had become complicated after Miss Boyce, who had been diagnosed with type 1 Diabetes in August 2010, had picked up a chest infection the previous week.
Her family had complained that a visit to her GP should have picked up the onset of DKA – a potentially lifethreatening complication of diabetes caused by a lack of insulin in the body. But the inquest heard evidence from experts who said the GP had conducted a proper examination.
The inquest heard that neither Dr Gupta or Dr Tiju picked up on the patient feeling drowsy, drinking lots of water, shallow and rapid breathing and vomiting.
The GPs, both of whom are believed to no longer work at the outof-hours telephone service, were also criticised for not arranging a face-toface consultation or at least insisting on speaking to the patient in person.
The teenager died the next day, on February 6, 2012, in Morriston Hospital. The cause of death was recorded as diabetic ketoacidosis, plus an underlying infection and diabetes mellitus.
Independent expert Dr Stephen Hicks said: “Out-of-hours services should ensure that doctors and nurses have some training in telephone consultations; you have to ask more questions because you can’t see them face to face.”
Recording a narrative conclusion, Swansea’s acting senior coroner, Colin Phillips said: “Neither Dr Gupta or Dr Tiju spoke directly to Sammy-Jo Boyce and therefore missed opportunities to appropriately assess her condition.
“However in my view, whilst these failings were serious failings, they were not gross failings. The failings however had serious consequences.
“I accept the experts’ evidence that if a referral for emergency admission had been made after the two telephone consultations on February 5, 2012, it is likely that a diagnosis of DKA would have been made and that appropriate treatment would have been given. If this had occurred Sammy-Jo Boyce is likely to have survived.”
Stephen Bassett, current clinical leader for Abertawe Bro Morgannwg University Health Board’s out-ofhours GP service, told the inquest training had changed over the last five or six years.