Coroner criticises box-ticking culture of doctors as she hears how seven-week-old baby died of pneumonia after being taken to private out-of-hours clinic
Dr Shirley Radcliffe said GPs were obliged to practice 'defensive medicine' Axel Peanberg King originally diagnosed with viral infection
He died from pneumonia at the age of just seven weeks old
His parents had been in contact with private out-of-hours clinic HarmoniFirm has previously come under fire for poor levels of staffing
16:59 GMT, 28 February 2013
00:27 GMT, 1 March 2013
A coroner yesterday attacked the box-ticking culture among GPs after hearing how a desperately ill baby was not seen quickly enough.
Dr Shirley Radcliffe spoke out as she ruled that Axel Peanberg King died following ‘wholly inadequate’ decisions made by an out-of-hours doctor based on a one-minute phone call.
Dr Muttu Shantikumar ignored the pleas from Linda Peanberg King for her seven-week-old son, who was suffering from pneumonia, to be seen as soon as possible, an inquest was told.
Axel Peanburg King with his mother Linda. He died from pneumonia despite his mother calling and visiting a privately-run out of hours GP centre several times
He downgraded her call from ‘urgent’
to ‘routine’ and left her waiting for nearly four hours for an
appointment because he did not deem the baby’s situation an emergency.
With her dying son in her arms, the
35-year-old mother then had to wait in line behind six non-emergency
patients at the private out-of-hours GP service Harmoni, at Whittington
Hospital in Archway, north London.
St Pancras Coroner’s Court heard that
it was only when an off-duty nurse spotted that Axel had turned ‘grey
and floppy’ that he received emergency care – but by then it was too
late and he died at the hospital from bronchopneumonia five days after
Recording a narrative verdict, Dr Radcliffe described the
brief phone conversation between Dr Shantikumar and Mrs Peanberg King as
‘wholly inadequate’, adding that the doctor ‘asked insufficient
She said: ‘It lasted only one minute and the entries made are clearly at odds with the evidence from Mrs Peanberg King.’
Mrs Peanburg King told the inquest that when she arrived at the private GP clinic with Axel, who was no longer breathing, she was told by a receptionist to 'wait in line'
Axel’s mother said that after she
spoke to Dr Shantikumar at 12.45pm on November 3 last year, he made them
an appointment for 4pm, but when they arrived they had to queue to be
By this time Axel had become unresponsive and he went into cardiac
arrest. Mrs Peanberg King, of Islington, north London, said that on
October 31 she took Axel to her own GP, who diagnosed him with a viral
The next day, when his condition had not improved, she took him to the Harmoni centre.
She saw Dr Kuljeet Takhar, who told
her Axel’s lungs were clear and gave them a prescription for antibiotics
so they would not have to go back if the baby’s condition changed.
The coroner described Harmoni’s
medical services as ‘robust’, adding ‘call backs and consultations up
until 3 November were admitted appropriately’.
She added: ‘It is
impossible to say whether intervention at an earlier stage would have
changed the tragic outcome.’
Seven-week old Axel was treated at the Harmoni centre at the Whittington Hospital in north London (pictured) before he died
Mrs Peanberg King had said earlier in
the inquest that she believed her previous visit to Dr Takhar had been
insufficient. But Dr Radcliffe said she was satisfied that his
consultation was carried out in an appropriate manner.
During the inquest, the coroner said
GPs were obliged to practise ‘defensive medicine’ where the focus is on
writing lengthy notes rather than on ‘spending time assessing
individuals and communicating with the family’. She said: ‘We live in an
age where there is an assumption that if it isn’t written down, it
isn’t done, so we can have a situation where doctors do very little in
their consultation but have perfect records.’
On the other hand, she added: ‘We can
have perfectly good consultations with doctors that cover the ground but
are no good on paper simply because they have not ticked every box,
which is worrying.’
Axel’s death is the latest controversy
involving Harmoni – the largest private provider of NHS out-of-hours GP
services in the country which is responsible for the care of eight
Last year there were allegations that
the service is so short-staffed it is regularly unsafe – and that
managers were regularly sending out ‘mayday’ text messages requiring
urgent cover for shifts where there was no one on duty.
After the inquest, Mrs Peanberg King
and her husband, Alistair, 36, a media manager, said: ‘We believe there
are still many questions to answer about the safety of the service
provided by Harmoni.
‘We do not believe that anyone hearing
all the evidence in this case could have full confidence in Harmoni’s
out-of-hours services. We are now considering all our options to prevent
any other children from falling through the net.’