Inquests: harrowing but essential to progress.

As clinical negligence partner Rosamund Rhodes-Kemp reflects on the tragic and avoidable death of a young girl, she also applauds the role of the inquest as a catalyst for change … 

Some months ago we were instructed to look into the death of a 4 year-old child and I agreed to represent the family.

The little girl was one of three children – she had two brothers. The family were originally from Afghanistan. Mum spoke little English, so the father was the one who tended to take the children to the doctor if they were ill.

In September 2010 he took his daughter to the GP with a sore throat and fever and was sent home with medication. As she got worse, he then tried an out-of-hours doctors’ service, then an A & E department – all based in London. Her condition continued to deteriorate with each day and, finally, he took her to a London teaching hospital, where she was admitted.

The admitting A & E doctor suggested a possible cardiac cause for her symptoms but, unfortunately, this was never followed up. The child’s care was transferred from one locum doctor to another, and then to night paediatric staff who were all new to the hospital and unfamiliar with the procedures. This was due to a six-month rotation which meant that all junior medical staff changed at the same time, twice a year. A consultant was on call but not actually in the hospital, as there is no night-time consultant cover at this hospital.

The registrar described the night as busy and, although she called the consultant about the child, the latter did not attend in person but instead advised over the phone.

The registrar spoke to a doctor in PICU who did actually see the child at one point to re-insert a catheter that had malfunctioned. But he was also new, and not experienced in paediatrics.

Overnight the little girl’s condition deteriorated. However the nursing staff did not appreciate this as one of them was on her break at the crucial time, and the registrar did not realise the significance of the changing clinical picture. This was made more difficult due to the lack of basic observations carried out by nursing staff.

When the senior nurse and consultant on duty came on in the morning, they immediately realised the seriousness of the child’s condition, and she was rushed to PICU for resuscitation. Sadly she died shortly afterwards. She had suffered a rare inflammatory condition of the heart which could have been picked up earlier if a simple test had been done and analysed. Ironically it was done, but not reviewed.

The inquest took place at Westminster Coroner’s Court, and a large number of witnesses were called by the coroner to give evidence.

He had also got a specialist in this cardiological problem to report and give evidence at the inquest. His conclusion – which he stuck to through hostile cross examination – was that the correct treatment was perfectly possible and would have saved the child’s life.

The Inquest lasted for three days, and the little girl’s father was present throughout some very harrowing evidence.

We were expecting some criticism of the practice and procedures. What we were hoping for was a verdict that included ‘a lack of care and recommendations for change’ by the coroner – a so-called ‘Rule 43 letter’. The verdict was all this and more.

The coroner rightly criticised the six-month rotation. He has written to the dean of the medical school insisting that this be staggered, so the entire hospital is not left to be run by new doctors two weeks a year – clearly a very dangerous situation.

He is also writing to suggest that the basic screening test for this condition is carried out on all children who attend the hospital with symptoms of infection and unexplained and unusual pulse and heart rate.

The father was very brave throughout. At the end he was pleased that there had been a thorough investigation via the inquest, and felt that a similar tragedy was far less likely to happen to someone else’s child.

The day before the hearing we had received a letter with a full admission of negligence, and that it was this that had caused the death. But the actual sifting of evidence and questioning of witnesses meant a lot to the father as, to him, justice was seen to be done.

On the last day – at my request – he brought pictures of his daughter in so that I could see her. She was beautiful.

This was a harrowing and emotional journey for all those involved. But the detailed nature of the inquiry will be of benefit not just to this family, but to many others whose children fall ill during the week of the six-month rotation. Lessons were learned and practices are to change.

In our work you cannot wish for better than that, even though part of you always longs to turn the clock back and prevent an avoidable death.