Inquest into death of Isabel Gentry
University Hospital Bristol NHS Trust found responsible of ‘Neglect’ following teenage death from meningitis
The Inquest took place at Bristol Coroner’s Court last week, Martin Pettingell, Partner, represented the family at the Inquest.
Isabel was studying for her AS exams when she became ill on 17 May 2016. Her mother; Claire Booty, telephoned the 111 service seeking further advice. Izzy confirmed she was suffering from headache, neck pain and fever. A request was made for an out of hours GP to call back. When the doctor called back Izzy was being sick and then fainted. Claire Booty was advised to hang up and call an ambulance immediately.
Izzy was admitted to the Emergency Department at the Bristol Royal Infirmary (BRI) in the early hours of the morning on 18 May 2016. Following an assessment by the triage nurse she was seen by the doctor. An examination was carried out. Mrs Booty was concerned that the examination was not ‘thorough or logical’. A history was recorded of ‘loose stools, malaise and lethargy’. Izzy’s temperature and heart rate remained raised in hospital despite treatment with paracetamol and fluids. The doctor made a diagnosis of suspected gastroenteritis and discharged her shortly after 5am.
Later that day her mother contacted the GP surgery to request a home visit but received a call back from the GP mid afternoon and a prescription was provided for anti-sickness medication. No home visit was arranged.
A further call early evening resulted in an emergency admission back to the BRI by ambulance. On arrival the Consultant diagnosed meningitis. Tragically Isabel’s condition deteriorated quickly thereafter and she was pronounced dead on 20 May 2016.
Shortly after the death the Trust carried out its own investigation and prepared a Root Cause Analysis Report concluding that all care including the decision to discharge was appropriate.
The GP surgery also carried out their own independent enquiry and accepted that there were failings in respect of the handling of the telephone call and decisions made.
Prior to the Inquest the Coroner made the decision to obtain independent evidence from an A&E Consultant; Dr Holburn to comment on the treatment in the BRI and also a Causation report from a Dr Ninis a Consultant in Infectious Diseases. Both reports criticised the assessment by the doctor in the Emergency Department, the decision to discharge from hospital and the conclusions reached within the Root Cause Analysis. Dr Ninis gave evidence to the effect that if Izzy had remained in hospital and not discharged her condition would have deteriorated, she ought to have received appropriate treatment including antibiotics and if that action had been taken she would have survived.
Following the Inquest the Coroner; Maria Voisin made the following findings:
- The doctor in the BRI did not take an accurate history.
- The observations and bloods taken in hospital were abnormal.
- The observations and bloods were not considered in light of the fluid and medication prescribed.
- A diagnosis of gastroenteritis was not appropriate.
- The previous case of meningitis was not acted upon.
- No senior review was carried out.
The Coroner reached the conclusion that Izzy died from Natural Causes, (i.e. Meningococcal Meningitis), contributed by neglect.
The Coroner confirmed that she was under a duty to prevent future deaths and would make recommendations that the Men B vaccination be extended to cover Izzy’s age group and would also be preparing a report for the Bristol Royal Infirmary.
Vinny Jones, Chief Executive of Meningitis Research Foundation (MRF) commented after the case and said:
“It is because of cases such as Izzy’s that MRF has campaigned tirelessly to raise awareness of meningitis and septicaemia, and for vaccines to protect vulnerable children and teenagers from these deadly infections. We publish guidelines and educational materials for health professionals to help them recognise the illness and deliver life saving treatment.”
This case highlights that families would have considerable difficulty accessing justice if the Department of Health succeed in introducing fixed fees for clinical negligence claims for all cases where damages are worth less than £25,000. Currently clinical negligence solicitors, SCIL (Specialist Clinical Injury Lawyers) and AVMA are in consultation with the Department of Health and a key recommendation is that all fatal cases should be excluded from fixed fees.
In this particular case all interested parties in the Inquest were represented at the Inquest by advocates. It is not always easy to recover the Claimant’s costs of such representation and if those cases fall within the ‘fixed fee regime’ the costs would simply be unrecoverable and the families would have to pay for their own legal representation or proceed with no legal assistance. On a five day Inquest those costs are likely to be in the region of £10,000, an expense that many could simply not afford.
Kerry Fifield said:
“This was a tragic case and one where the situation was made significantly worse by the manner in which it was handled by the hospital following Isabel’s death. Even when the Trust carried out their own internal investigation it lacked any real critical analysis of the assessment carried out by the doctor. When the Trust received the independent reports obtained by the Coroner, which were critical of the care received, the Trust still failed to accept that they had done anything wrong.”
If you or a member of your family have been affected by delay in diagnosis or medical negligence relating to the treatment of meningitis please get in touch or call one of our medical negligence specialists on 0800 316 8892.