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| Version 2 | Version 3 |
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| Sent home baby would have lived | Sent home baby would have lived |
| (about 12 hours later) | |
| A baby would have survived had she not been discharged from hospital, an inquest has heard. | A baby would have survived had she not been discharged from hospital, an inquest has heard. |
| The Cardiff coroner said a senior registrar failed to recognise how serious Aleesha Evans's condition was. | The Cardiff coroner said a senior registrar failed to recognise how serious Aleesha Evans's condition was. |
| A narrative verdict was recorded on Aleesha, from Bettws, Newport, who died the day after she left the Royal Gwent. | A narrative verdict was recorded on Aleesha, from Bettws, Newport, who died the day after she left the Royal Gwent. |
| The coroner said the doctor had been involved in a death at another hospital and she was disappointed her report on that had not been passed on. | The coroner said the doctor had been involved in a death at another hospital and she was disappointed her report on that had not been passed on. |
| Cardiff Coroner Mary Hassell said the doctor, Salawat Abdul-Salam, had been involved in a death at the University Hospital of Wales two years earlier, and she was disappointed that her report on this previous case had not been given to the Gwent Healthcare Trust. | Cardiff Coroner Mary Hassell said the doctor, Salawat Abdul-Salam, had been involved in a death at the University Hospital of Wales two years earlier, and she was disappointed that her report on this previous case had not been given to the Gwent Healthcare Trust. |
| Ms Hassell said she was concerned that doctors' records might still not be passed onto a new employer. I just took it for granted that anything abnormal would have been mentioned to me Dr Salawat Abdul-Salam | Ms Hassell said she was concerned that doctors' records might still not be passed onto a new employer. I just took it for granted that anything abnormal would have been mentioned to me Dr Salawat Abdul-Salam |
| "I will raise this at the highest level, if it's happening here it might be happening somewhere else," the coroner said. | "I will raise this at the highest level, if it's happening here it might be happening somewhere else," the coroner said. |
| "If Aleesha had been referred to the paediatric team instead of being discharged, she would have been treated with antibiotics and she would have survived." | "If Aleesha had been referred to the paediatric team instead of being discharged, she would have been treated with antibiotics and she would have survived." |
| The inquest heard Ms Hassell had previously written a report about Dr Abdul-Salam. | The inquest heard Ms Hassell had previously written a report about Dr Abdul-Salam. |
| Dr Abdul-Salam had discharged a patient from the University Hospital of Wales in 2004 after incorrectly diagnosing him as suffering from constipation, Ms Hassell said. | Dr Abdul-Salam had discharged a patient from the University Hospital of Wales in 2004 after incorrectly diagnosing him as suffering from constipation, Ms Hassell said. |
| That patient, Colin Perriam, collapsed the next day and subsequently died. | That patient, Colin Perriam, collapsed the next day and subsequently died. |
| Aleesha died in August 2006 after she suffered multiple organ failure triggered by meningococcal septicaemia, the inquest was told. | Aleesha died in August 2006 after she suffered multiple organ failure triggered by meningococcal septicaemia, the inquest was told. |
| Shiree Hanbury was told by the hospital to give her daughter Calpol | Shiree Hanbury was told by the hospital to give her daughter Calpol |
| Her parents Shiree Hanbury and Craig Evans were told by staff at the Royal Gwent Hospital where she had been taken the day before that she had a viral infection and needed only Calpol and Nurofen. | Her parents Shiree Hanbury and Craig Evans were told by staff at the Royal Gwent Hospital where she had been taken the day before that she had a viral infection and needed only Calpol and Nurofen. |
| The inquest heard Aleesha was taken home but later rushed back to the University Hospital of Wales in Cardiff, where doctors could not save her. | The inquest heard Aleesha was taken home but later rushed back to the University Hospital of Wales in Cardiff, where doctors could not save her. |
| The two-day inquest heard how the baby had been referred to Dr Abdul-Salam, a specialist registrar, when she was admitted to the Royal Gwent's accident and emergency department. | The two-day inquest heard how the baby had been referred to Dr Abdul-Salam, a specialist registrar, when she was admitted to the Royal Gwent's accident and emergency department. |
| Senior House Officer Dr Owen Rees, who first assessed the baby, said he believed she had an infection, but he did not know the cause. | Senior House Officer Dr Owen Rees, who first assessed the baby, said he believed she had an infection, but he did not know the cause. |
| He said he highlighted the baby's raised pulse rate and high temperature of 37.9C. | He said he highlighted the baby's raised pulse rate and high temperature of 37.9C. |
| We have been suffering for two years, and are still trying to come to terms with our sad loss Statement by Aleesha's parents | |
| Dr Abdul-Salam said Dr Rees had not shown her the observation chart but she admitted she should have asked for the readings. | Dr Abdul-Salam said Dr Rees had not shown her the observation chart but she admitted she should have asked for the readings. |
| When asked by the coroner why she did not, Dr Abdul-Salam replied: "I can't tell you why not. It was so busy. | When asked by the coroner why she did not, Dr Abdul-Salam replied: "I can't tell you why not. It was so busy. |
| "I just took it for granted that anything abnormal would have been mentioned to me." | "I just took it for granted that anything abnormal would have been mentioned to me." |
| Shortly before she was sent home, Aleesha's temperature had risen to 39C despite the fact that she she had been given Ibuprofen in a bid to reduce it. | Shortly before she was sent home, Aleesha's temperature had risen to 39C despite the fact that she she had been given Ibuprofen in a bid to reduce it. |
| Dr Abdul-Salam said if she had been aware of that, then "the patient would not have been discharged". | Dr Abdul-Salam said if she had been aware of that, then "the patient would not have been discharged". |
| She said she believed Aleesha was suffering from a "flu-like illness." | She said she believed Aleesha was suffering from a "flu-like illness." |
| She also said she did not realise the seriousness of the situation as the baby seemed to have improved during her time at the hospital and was interacting with doctors and her parents. | She also said she did not realise the seriousness of the situation as the baby seemed to have improved during her time at the hospital and was interacting with doctors and her parents. |
| No charges were brought after Aleesha's death, Gwent Police said. | No charges were brought after Aleesha's death, Gwent Police said. |
| The Crown Prosecution Service considered a charge of manslaughter by gross negligence but it was dropped because of a lack of evidence. | The Crown Prosecution Service considered a charge of manslaughter by gross negligence but it was dropped because of a lack of evidence. |
| Additional procedures | Additional procedures |
| In a statement read outside the court, Aleesha's family said they believed she would have lived to celebrate her third birthday last Monday if hospital procedures has been properly carried out. | In a statement read outside the court, Aleesha's family said they believed she would have lived to celebrate her third birthday last Monday if hospital procedures has been properly carried out. |
| They said: "We have been suffering for two years, and are still trying to come to terms with our sad loss. | |
| "We hope, as a family, no-one else has to go through what we have endured, and sincerely hope that lessons have and will be learned". | "We hope, as a family, no-one else has to go through what we have endured, and sincerely hope that lessons have and will be learned". |
| After the inquest Dr Grant Robinson, medical director of Gwent Healthcare NHS Trust, said they were "deeply sorry for Aleesha's "tragic death" and they had failed to provide the right standard of care. | After the inquest Dr Grant Robinson, medical director of Gwent Healthcare NHS Trust, said they were "deeply sorry for Aleesha's "tragic death" and they had failed to provide the right standard of care. |
| Dr Robinson said more account should have been taken of the baby's raised heartbeat and temperature and she should not have been discharged. | Dr Robinson said more account should have been taken of the baby's raised heartbeat and temperature and she should not have been discharged. |
| The NHS trust has carried out its own investigation and put in place additional procedures that A & E staff must carry out when dealing with sick children. | The NHS trust has carried out its own investigation and put in place additional procedures that A & E staff must carry out when dealing with sick children. |
| A spokesperson for the Welsh Assembly Government said: "We would like to express our sincere condolences to the family and friends of the young girl who died. | A spokesperson for the Welsh Assembly Government said: "We would like to express our sincere condolences to the family and friends of the young girl who died. |
| "We would expect Gwent Healthcare NHS Trust to consider the evidence to the inquest and the verdict carefully and take any necessary action." | "We would expect Gwent Healthcare NHS Trust to consider the evidence to the inquest and the verdict carefully and take any necessary action." |
| Health Minister Edwina Hart has asked for a copy of the trust's investigation, the spokesperson added. | Health Minister Edwina Hart has asked for a copy of the trust's investigation, the spokesperson added. |