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Inquest

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Liverpool inquest starts following the alleged preventable death of 15-month-old girl

An inquest into the alleged avoidable death of 15-month-old Evie Crandle has started in Liverpool.

Evie had been taken to Whiston Hospital, in Merseyside, at 11.40am on 14th April 2018 with a high fever of 39.8C. She was refusing her breakfast and was vomiting. Her lips were alternating in colour between pink and blue and she was lethargic.

Medical staff dismissed her parents repeated queries, both on arrival and throughout that day, regarding a sepsis diagnosis and repeated requests for Evie to be given antibiotics.

Medical staff discharged the family at 4.30pm with Evie only provided with ibuprofen and calpol up to this point despite several tests and symptoms indicating sepsis. Evie’s parents brought her back to hospital within two hours because they were so concerned.

Evie was only given IV fluids more than 15 hours following her first admission when her condition had significantly deteriorated and she died two days later at Alder Hey Children’s Hospital where she had been transferred following an admission into critical care.

Evie’s parents, 31-year-old Sam McNeice and her partner 35-year-old Phil Crandle, said: “Evie was our beautiful little girl and she made our lives perfect. We celebrated what would have been her 2nd birthday less than three weeks ago with family and friends enjoying her favourites of pizza and ice cream.

“We still can’t believe that she has gone and we cry every single day. We were very aware of the symptoms of sepsis when Evie suddenly became ill. We asked the nurse immediately on arrival at Whiston Hospital whether Evie had sepsis but she reassured us that she was not concerned about Evie and that she probably had a urine infection.

“Evie met the criteria to start the sepsis pathway at triage but this didn’t happen. Evie’s condition continued to get worse throughout the day and we repeatedly asked medical staff if she had sepsis and when she would be given antibiotics but this was ignored. Several tests were carried out verifying the presence of an infection and her body temperature was so hot that we had her stripped and in front of a fan at one point. Her hands and feet were very cold and we were very clear in our minds that she had sepsis but no one acted on this until it was too late.”

Representing the family at the inquest medical negligence lawyer Diane Rostron commented: “This is a truly tragic case. Evie’s parents were very well informed about the symptoms of sepsis and had persistently tried to alert staff. Despite Evie’s health clearly deteriorating and various tests showing that she was suffering from an infection, the family were sent home only to return a little over two hours later as further signs of sepsis became present.

“It is incredible that by 8.30pm that evening that Evie had still not been given the urgent treatment that she required. Her parents were instead advised that medical staff planned to give her intravenous fluids but that no one was available to administer the treatment.

“Phil and Sam were so desperate that Phil even offered to help with the procedure himself. The National Institute of Clinical Excellence (NICE) has very clear sepsis guidelines in place. The NICE guidelines clearly recommend that within one hour of sepsis being suspected, and even before a definite diagnosis, antibiotics must be given.

“Several medical staff at Whiston Hospital were involved in the care of Evie that day and all failed to follow the national guidelines resulting in what we believe was Evie’s entirely avoidable death.

“We look forward to the Coroner’s findings and sincerely hope that the NHS Trust now puts urgent measures in place to ensure not only that all its staff are adequately trained in recognising sepsis symptoms, but also that the Trust ensures that all staff adhere to the NICE guidelines. The staff not only failed to follow the national guidelines, but also failed to follow the Trust’s own guidelines.”

Sam and Phil continued: “We are now expecting our second daughter and feel absolutely terrified. Evie was born at Whiston Hospital but we will be having our second child elsewhere as we can’t face being anywhere near there and have serious concerns about the staff. We need to know why the hospital ignored the national sepsis guidelines and its own protocols and why our daughter is no longer with us.”

Evie’s parents are being supported by child bereavement charity Love Jasmine and the bereavement team at Alder Hey Children’s Hospital.

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 For media enquiries please contact Rana Audah on 07793 356 439 or at rana.audah@gmail.com

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Coroner returns rare finding of neglect following death of Lytham man

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Coroner returns rare finding of neglect following death of Lytham man

Blackpool assistant coroner Claire Doherty yesterday delivered a verdict of death by natural causes due to neglect following the death of 45-year-old Paul Wilkinson at Blackpool Victoria Hospital in May 2017.

The father of three was admitted as a priority patient into Blackpool Victoria Hospital on Friday 26 May complaining of severe abdominal pain and died just six days later from multiple organ failure and sepsis.

The Lytham based salesman had been perfectly healthy until two weeks prior to admission when he started suffering with muscle aches. A visit to his local GP resulted in a diagnosis of a suspected rheumatological condition and steroids were prescribed which initially eased his symptoms.

His partner, a former bowel cancer screening nurse at Blackpool Victoria Hospital, Louise Johnson said: “I am pleased that the coroner’s verdict has confirmed what I already knew but it’s very hard for our family. Paul had not slept well due to significant pain and was rushed to hospital at 6am on the Friday before the Bank Holiday weekend and admitted to A&E as a priority case.

“Paul was not one to complain but he was left in the corridor for more than an hour at one point and was shouting out in pain. The staff didn’t take his pain seriously despite two indicators showing that he had an infection. Over the course of the next six days his condition just got worse but he was initially only seen by junior doctors. No one seemed to take his condition seriously although he was displaying several very serious symptoms.”

Instructed to represent the family medical negligence specialist Leanne Devine at Addies commented: “We are very pleased with the coroner’s finding of neglect as we believe that Paul Wilkinson would have made a full recovery had he been given adequate medical care at Blackpool Victoria Hospital.

“Paul was admitted as a priority patient but was given the level of care in the first few critical days as someone suffering a common cold. He should have been prescribed antibiotics on day one which could have saved his life.

“There were no trained nurses available to care for him and his medical care was initially left to junior doctors and healthcare assistants. Paul suffered very poor care during his final days and despite being admitted to Blackpool Victoria Hospital as a priority, was not seen by a consultant until 54 hours later during which his health progressively deteriorated.

“Our investigations to date have found that there were multiple failures in giving Paul the medical attention and treatment required. Paul’s condition deteriorated rapidly during his six day stay and we believe that his death was entirely preventable. We will now be pursuing the Trust for medical negligence.”

Paul leaves behind 10-year-old twins and a son aged two and a half years old.

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Coroners to investigate stillbirths – what this means for birth safety

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Coroners to investigate stillbirths – what this means for birth safety

In November 2017, the Health Secretary, Jeremy Hunt, announced plans for a new maternity strategy aimed at reducing the number of stillbirths in the UK. A key part of this plan is offering an independent investigation to families who suffer a stillbirth or life changing birth injury to their child to find out what went wrong. This is intended to help identify if mistakes were made before, during or immediately after the birth.

There have long been calls for it to be made a legal requirement for the deaths of stillborn babies to be referred to coroners. While some coroners do request that they be informed of all stillbirths, this was not enforceable or universally the case. With the UK having one of the worst rates of still birth in the western world (currently 4.5 per 1000 births) being able to investigate the circumstances surrounding these deaths is essential to help identify where mistakes are being made and improve birth safety.

 The Chief Coroner, Judge Mark Lucraft QC, had previously highlighted the issue that doctors are not legally required to report deaths to a coroner in his 2017 annual report to the Lord Chancellor. This means that opportunities are potentially being missed to learn from mistakes that were made by medical staff during a pregnancy or birth that resulted in the baby’s death.

 Under the new plans, any family who experiences a stillbirth, early neonatal death or severe brain injury will be referred to the new Healthcare Safety Investigation Branch, who will look into the circumstances surrounding the death or injury. Additionally, full-term stillbirths will now routinely be investigated by coroners.

 The aim of this new strategy is to ensure that where mistakes are being made in the care pregnant women and their babies receive before, during and after a birth, the reasons are identified so lessons can be learned.

 Mr Hunt said: “Countless mothers and fathers who have suffered like this say that the most important outcome for them is making sure lessons are learnt so that no-one else has to endure the same heartbreak. These important changes will help us to make ‎that promise in the future.”

 The Department of Health and Social Care also announced that it is bringing forward the date by which it intends to halve rates of stillbirths, neonatal and maternal deaths, and brain injuries occurring during or soon after birth from 2030 to 2025.

 It has to be hoped that, by standardising practices around referring stillbirths to coroners and giving families the option to have their child’s death or birth injury independently investigated, the number of stillbirths and birth injuries can be dramatically decreased while giving families some degree of comfort and closure.

These changes to how stillbirths and birth injuries are handled should also make is easier for families to claim compensation where appropriate by making it faster and easier to identify where medical mistakes were to blame for what happened. This should be of particular relevance to parents whose child has been left with a serious birth injury as compensation can make a significant difference to their child’s ability to live an independent, happy and fulfilling life.

If your family has suffered a significant injury due to medical negligence, contact our friendly team on 01253 766 559.

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Blackpool Health Trust's poor review poses death risks, says Coroners

Click to read the full article on The BBC Website. 

More patients could die at a hospital unless health bosses review the way serious incidents are investigated, a coroner has warned.

Blackpool coroner Alan Wilson raised his concerns over the internal review into a woman's death following routine surgery at Blackpool Victoria Hospital.

He said Blackpool Teaching Hospitals NHS Foundation Trust's probe into care given to Pamela Briggs was "flawed".

The trust said it has "already begun" a review of its serious incident process.

Missed opportunity

Mrs Briggs' lawyer, Diane Rostron, said she began to suffer with chest pains a week after her operation. 

"An ECG showed irregularities and that was a clear sign she had had suffered a heart attack. Unfortunately she didn't receive any interventional treatment for that. 

"The heart attack was caused by a blocked stent and a simple procedure could have relieved that blockage and may well have ensured Pam survived."

Ms Rostron said the 69-year-old then suffered a second heart attack at St Catherine's Hospice in Preston and died on 13 February after a "crucial window of opportunity" to treat her was missed. 

Mrs Briggs' sister, Chris Walton, said her sibling would still be alive if "appropriate treatment been given" and criticised the trust's investigation for "papering over very serious cracks".

Mrs Walton said the trust took almost seven months to produce its report - contrary to the 60 days in NHS guidelines - and she was "appalled" to discover the probe had been conducted by the doctor and matron responsible for her sister's care - while a key witness was ignored.

"I was dumbfounded; I felt that we were being laughed at," she said.

The coroner has now issued a "regulation 28 report" - a document aimed at preventing future deaths - to the trust and to the chief coroner of England and Wales.

Coroner's concerns 

  • The review was "not robust or thorough enough"

  • Failure to speak to a key witness - the cardiology registrar - meaning the review was based on "inadequate information". The coroner said this meant recommendations were "ill-informed" and "flawed" and "risks placing future patients in jeopardy"

  • One of the authors of the report was the surgeon who operated on Mrs Briggs which risked the perception of a lack of transparency and faith in the recommendations and a risk of failing to amend inappropriate practices

A spokesperson for the trust said the coroner was "not critical of the care given" and found evidence given by staff "extremely helpful" but acknowledged he "expressed some concerns regarding the quality of its incident report".

The trust, which has until January to respond, said a review is under way and "any proposals for changes" will be given to the coroner.

Mrs Walton said: 'This can't all be for nothing. Pam's death has to at least make them look at their actions and change their ways so that future deaths are avoided."

Click to view the video on The BBC Website.

If your family has suffered a significant injury due to medical negligence, contact our friendly team on 01253 766 559.

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Risk of future deaths... Coroner's concerns

Pamela died at Blackpool Victoria Hospital earlier this year. Her sister, Christine, was concerned about the care she had received and following extensive enquiries chose me to represent her. The Coroner held an inquest into Pam's death on 4 November. He took the unusual step of issuing a Regulation 28 Report because he was so concerned about the risk of future deaths. I will continue to represent Christine in the months ahead.

Click to read the full article on The Gazette's Website.

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Charlie: Outcome of Coroner's Inquest

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Charlie: Outcome of Coroner's Inquest

Charlie's parents believe that he was let down by the care he received at birth, resulting in brain damage and again when he became unwell at four and a half years of age, resulting in him sadly dying.  Representing our Clients at Coroner's Inquests is part of what we do.   Press release statement issued on behalf of Charlie's parents following the inquest on 10 November 2016, by Diane Rostron.   Charlie was our beautiful little boy. He was born very early and unfortunately we believe that mistakes were made during his delivery causing him to be very badly bruised. In turn, we believe that this caused him to bleed into his brain, causing him brain damage. After many months in hospital he was able to come home with us. Despite his many problems, he was very much loved by us, his parents, and by his brothers and sisters. He was a very important part of all our lives, and his life, although different from able bodied children, was full of joy and purpose.  In March of this year, Charlie became very agitated and upset and we took him into Blackpool Victoria Hospital. He was diagnosed with pneumonia and, against our expectations, was discharged home the same day on an antibiotic. We only agreed to take him home because we were assured that the pneumonia had been caught early and that the antibiotic would soon ‘kick-in’. Unfortunately, his condition deteriorated and the next day we took him back to Blackpool Victoria Hospital. The inquest heard that he was admitted at lunchtime. He was requiring oxygen and was bleeding. Despite this, he was not seen by a doctor until mid-afternoon and no investigations or treatment was provided until early evening. Sadly by then it was too late. He was transferred on a life support system to Alder Hey Children’s Hospital in Liverpool where he died. We were told that he had died from sepsis.  The Coroner decided that he had died of natural causes. It is our sincere belief that his death could have been prevented if our concerns had been listened to and acted upon. We believe that he was let down both at the start and the end of his life. In between he had some very good care from a number of doctors and nurses, and as a family we pay tribute to them. However, we believe that Charlie should not have suffered the brain damage he did at birth and that he should not have died when he did and in the manner he did. We have been assisted by our Solicitor, Diane Rostron, and with her on-going help we will fight for the justice Charlie deserves.   Hospital 'not to blame' for child's death -  Click to read the full article on The Gazette's website.

Charlie's parents believe that he was let down by the care he received at birth, resulting in brain damage and again when he became unwell at four and a half years of age, resulting in him sadly dying.

Representing our Clients at Coroner's Inquests is part of what we do.

Press release statement issued on behalf of Charlie's parents following the inquest on 10 November 2016, by Diane Rostron.

Charlie was our beautiful little boy. He was born very early and unfortunately we believe that mistakes were made during his delivery causing him to be very badly bruised. In turn, we believe that this caused him to bleed into his brain, causing him brain damage. After many months in hospital he was able to come home with us. Despite his many problems, he was very much loved by us, his parents, and by his brothers and sisters. He was a very important part of all our lives, and his life, although different from able bodied children, was full of joy and purpose.

In March of this year, Charlie became very agitated and upset and we took him into Blackpool Victoria Hospital. He was diagnosed with pneumonia and, against our expectations, was discharged home the same day on an antibiotic. We only agreed to take him home because we were assured that the pneumonia had been caught early and that the antibiotic would soon ‘kick-in’. Unfortunately, his condition deteriorated and the next day we took him back to Blackpool Victoria Hospital. The inquest heard that he was admitted at lunchtime. He was requiring oxygen and was bleeding. Despite this, he was not seen by a doctor until mid-afternoon and no investigations or treatment was provided until early evening. Sadly by then it was too late. He was transferred on a life support system to Alder Hey Children’s Hospital in Liverpool where he died. We were told that he had died from sepsis.

The Coroner decided that he had died of natural causes. It is our sincere belief that his death could have been prevented if our concerns had been listened to and acted upon. We believe that he was let down both at the start and the end of his life. In between he had some very good care from a number of doctors and nurses, and as a family we pay tribute to them. However, we believe that Charlie should not have suffered the brain damage he did at birth and that he should not have died when he did and in the manner he did. We have been assisted by our Solicitor, Diane Rostron, and with her on-going help we will fight for the justice Charlie deserves. 

Hospital 'not to blame' for child's death - Click to read the full article on The Gazette's website.

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