‘Give parents second opinion’ – coroner speaks out after girl’s misdiagnosis tragedy
CHANGES must be made to prevent the errors that led to the misdiagnosis of a little girl who died after contracting meningitis, a coroner has said.
Kate Pierce, seven, from Rossett, near Wrexham, died in 2013 after a junior doctor failed to spot she was suffering from meningitis in 2006, resulting in severe brain damage.
Halenahalli Vijayakumar instead diagnosed viral tonsillitis when Katie was taken to hospital in 2006. That blunder and neglect had contributed to her subsequent death, an inquest in September heard.
The jury found that the doctor examined Kate while she was asleep.
Assistant coroner David Lewis has now issued a ‘prevention of future deaths’ notice due to his concerns that correct procedures were still not in place at Betsi Cadwaladr University Health Board’s paediatric unit.
His first concern stemmed from the uncertainty over when children should be provided with second opinions.
It comes after Kate’s parents Mark and Dianne asked Dr Vijayakumar for a second opinion, but no recorded note was made of him doing so.
The lack of notes led to the junior doctor having to staunchly deny at the inquest that he lied about seeking out a second opinion.
Mr Lewis said: “There remains uncertainty about the circumstances in which a sick child should be seen by a senior paediatrician prior to discharge.”
He said two documents provided to him by the health board about discharging children “are silent as to whether a parental request for a second opinion should automatically lead to an examination of the child by the senior doctor”.
He added: “I am concerned that a lack of clarity about the health board’s expectations in this respect may continue to allow for the possibility of a child being discharged without a sufficient (and sufficiently senior) assessment having being made.”
Mr Lewis said he was also concerned about what was in place to ensure lessons are learned when a child is discharged and returns to hospital later with a worsening condition.
Kate was brought back into Wrexham Maelor Hospital 36 hours after she had been discharged and was diagnosed with meningitis.
Mr Lewis added: “I did not emerge from this evidence [during the inquest about protocols in place] with any confidence that there exist clearly defined and consistently applied criteria from ensuring that learning opportunities are being actively sought out and acted upon”.
Mr Lewis said he was concerned “too much is left to chance in the identification of matters requiring investigation, in the selection of the investigating staff and in the urgency of lessons being learned and acted upon”.
Gill Harris, the health board’s executive director of nursing and midwifery, said: “We would like to reiterate how very sorry we are for the distress this tragic incident has caused to Kate’s family and once again offer them our sincere condolences. The health board takes all the findings of the Coroner seriously and we are continuously working to improve the services we deliver.”
The board has until Boxing Day to respond to the coroner’s report