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Medics criticised on girl's death | Medics criticised on girl's death |
(about 3 hours later) | |
A coroner has criticised medical staff for not sharing information about a toddler who died of meningococcal septicaemia, a type of blood poisoning. | A coroner has criticised medical staff for not sharing information about a toddler who died of meningococcal septicaemia, a type of blood poisoning. |
Eighteen-month-old Fatama Barkhad was sent home from a Cardiff hospital after a doctor said she had a sore throat. | Eighteen-month-old Fatama Barkhad was sent home from a Cardiff hospital after a doctor said she had a sore throat. |
After developing a rash Fatama was readmitted but she died later that day. | After developing a rash Fatama was readmitted but she died later that day. |
The coroner said she did not think Fatama would have survived even if accurate information had been passed on. She recorded a narrative verdict. | The coroner said she did not think Fatama would have survived even if accurate information had been passed on. She recorded a narrative verdict. |
The first time Fatama's parents took her to the University Hospital of Wales, Cardiff, on 6 October, she was examined by a paramedic, then a triage nurse and finally Dr Shyama Velupillai, a GP working for an out-of-hours service. | The first time Fatama's parents took her to the University Hospital of Wales, Cardiff, on 6 October, she was examined by a paramedic, then a triage nurse and finally Dr Shyama Velupillai, a GP working for an out-of-hours service. |
Fatama's mother Hana Ismail was told by Dr Velupillai to give the little girl Calpol and seek medical help if her condition got worse. | Fatama's mother Hana Ismail was told by Dr Velupillai to give the little girl Calpol and seek medical help if her condition got worse. |
When the rash developed on her head and body less than five hours later, Fatama was rushed back to hospital. | When the rash developed on her head and body less than five hours later, Fatama was rushed back to hospital. |
I can't see whether, even if the course of events had been different, and even if Fatama had been kept in hospital, the outcome would have been different for her Coroner Mary Hassell | I can't see whether, even if the course of events had been different, and even if Fatama had been kept in hospital, the outcome would have been different for her Coroner Mary Hassell |
Doctors battled to save her but she died of meningococcal septicaemia the same day. | Doctors battled to save her but she died of meningococcal septicaemia the same day. |
The inquest heard that none of the health professionals who initially examined Fatama passed on accurate information about the little girl's condition, including her breathing rate and heart rate. | The inquest heard that none of the health professionals who initially examined Fatama passed on accurate information about the little girl's condition, including her breathing rate and heart rate. |
Cardiff coroner Mary Hassell said this was "worrying", but concluded that Fatama's treatment would have been the same if all the information was available. | Cardiff coroner Mary Hassell said this was "worrying", but concluded that Fatama's treatment would have been the same if all the information was available. |
She said: "I find it extremely unfortunate that out of three medical professionals, none saw the record of those going before them. | She said: "I find it extremely unfortunate that out of three medical professionals, none saw the record of those going before them. |
"The triage nurse did not see the record made by the emergency technician, and the general practitioner did not see the record made by the triage nurse, or the emergency technician. | "The triage nurse did not see the record made by the emergency technician, and the general practitioner did not see the record made by the triage nurse, or the emergency technician. |
"It seems to me a very, very unsatisfactory state of affairs." | "It seems to me a very, very unsatisfactory state of affairs." |
Reports | Reports |
Ms Hassell told the inquest she had written reports to the Cardiff and Vale NHS Trust and the Welsh Ambulance Services NHS Trust to voice her concerns. | Ms Hassell told the inquest she had written reports to the Cardiff and Vale NHS Trust and the Welsh Ambulance Services NHS Trust to voice her concerns. |
She said she was also concerned there were no written guidelines for triage nurses to follow when presented with a sick child. | She said she was also concerned there were no written guidelines for triage nurses to follow when presented with a sick child. |
But she concluded: "Given all of the evidence, I don't think, if the history had been taken accurately and the earlier observations had been known about, that ultimately this would have changed the course of events for Fatama." | But she concluded: "Given all of the evidence, I don't think, if the history had been taken accurately and the earlier observations had been known about, that ultimately this would have changed the course of events for Fatama." |
The coroner said she did not know if Fatama would have survived even if she had been admitted to hospital on her first visit. | The coroner said she did not know if Fatama would have survived even if she had been admitted to hospital on her first visit. |
She added: "I can't see whether, even if the course of events had been different, and even if Fatama had been kept in hospital, the outcome would have been different for her. I simply don't know." | She added: "I can't see whether, even if the course of events had been different, and even if Fatama had been kept in hospital, the outcome would have been different for her. I simply don't know." |
Condolences | |
Dr Hugo Dowd, paediatric accident and emergency consultant at the University Hospital of Wales, Cardiff, told the inquest that one in 20 children with the disease cannot be saved, no matter how early it is spotted. | Dr Hugo Dowd, paediatric accident and emergency consultant at the University Hospital of Wales, Cardiff, told the inquest that one in 20 children with the disease cannot be saved, no matter how early it is spotted. |
Ms Hassell recorded a narrative verdict, outlining the events surrounding Fatama's death. | Ms Hassell recorded a narrative verdict, outlining the events surrounding Fatama's death. |
Fatama's parents, Hana Ismail and Mustefa Barkhad, of Butetown, Cardiff, did not wish to comment after the inquest. | Fatama's parents, Hana Ismail and Mustefa Barkhad, of Butetown, Cardiff, did not wish to comment after the inquest. |
After the inquest Ian Lane, medical director of the Cardiff and Vale NHS Trust, said: "I would like to offer condolences on behalf of the trust to the family of Fatama Barkhad for their loss. | |
"I note the coroner recognised that it is unlikely that earlier admission would have changed the outcome or that the seriousness of her condition would have been recognised at 5.10am." | |
He said he would study the coroner's recommendations to decide what changes could be made to current systems. |
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