Toddler death 'avoidable' - coroner

The death of a toddler was “avoidable” after series of failures in her care by medics who failed to spot her fatal brain condition in time to save her, a coroner ruled today.

Two-year-old Alice Mason had successfully undergone treatment for a brain tumour two months before she was taken ill in March 2011.

She died days later, having developed fluid on the brain, an inquest at West London Coroner’s Court heard.

In a narrative inquest verdict, coroner Dr Sean Cummings stated: “Alice’s death was avoidable”.

He noted that Alice had died “prematurely” at home on March 31 2011 from her illness which had gone “undiagnosed and untreated”.

He ruled “there were a very large number of serious failures ” in Alice’s care and he would be making a report to NHS London with a copy to the Care Quality Commission about the issue.

The youngster’s care was shared between her family’s local district general hospital, Kingston Hospital in Surrey, cancer specialists at the Royal Marsden Hospital, in Chelsea, west London, and a neurosurgical team at St George’s Hospital, south London.

Dr Cummings accepted there “have been improvements in the main,” but added: “What I continue to have concerns about is the ability of the consultants to effectively lead their teams.”

The inquest heard that Professor Martin Gore, medical director of the Royal Marsden, who led an inquiry into Alice’s care at the hospital and Kingston Hospital following her death, found more than a dozen failings by medical staff.

Dr Cummings said the report had shown failures at “almost every pathway” of care given to the toddler including unclear information about her MRI scan, inadequate communication, lack of overall care plan, lack of monitoring of her hydrocephalus – or “water on the brain” – and a failure to listen to Alice’s parents.

Prof Gore told the inquest Alice’s death had “shaken many, many people within the organisation”.

“I don’t think anyone involved in this case will forget it,” he said. “I certainly won’t.”

The inquest heard that the parents were told at the Royal Marsden on March 23, 2011 that an MRI scan had shown some signs of fluid accumulation and Alice should be taken to Kingston Hospital if her symptoms worsened for a CT scan.

But by the time tests were carried out, Alice had suffered irreversible brain damage, caused by hydrocephalus and emergency surgery could not save her.

Lawyers for the family claimed there were also further delays in transferring Alice to St George’s Hospital and in the surgery taking place.

Alice’s parents Rosalind and Gareth Mason hugged after the coroner delivered his narrative verdict.

In a statement after the inquest, they said: “Our daughter’s death at two years of age, which the coroner has today described as ‘avoidable’, has devastated us.

“She died in pain whilst under the care of medical professionals in whom we had placed our trust and who we were forced to beg to get her the help she needed.

“Expert evidence has made clear that if the doctors had done what they should, Alice would be with us today.

“The inquest has clearly shown that despite Alice being under the ‘shared care’ of three hospitals, these hospitals did not work together as they should.

“We are grateful that the inquest into Alice’s death has at last allowed us to hear from the medical staff involved in Alice’s care and heard how an abject failure of leadership led to our daughter’s untimely death.

“The evidence has been shocking and should cause concern for all those who are patients of shared care systems across the UK.

“We would like to know what has been done and being done to ensure nothing like this ever happens to another family.

“We hope the serious concerns the coroner will now communicate to all parties, including the CQC and NHS London, will lead to a real change in the way care is provided to children in London and across the UK.”

Before bringing the inquest to a close, Dr Cummings turned to Mr and Mrs Mason and said: “I am very very sorry that you had to endure this and it has gone on for such a long time.

“You had Alice taken away from you in such a circumstance that was hasty. A parent I think you would want to be in a position where they can look after their children right the way through to the end.

“I am sorry and you have my sincere condolences.”

Source Article from http://uk.news.yahoo.com/toddler-death-avoidable-coroner-180450535.html

Toddler death 'avoidable' - coroner