Three-year-old girl died because hospital doctors failed to give her 'basic medical care', says coroner
Isla's blood pressure was 'unacceptably low', finds coronerShe suffered a catalogue of errors during surgery on her airways
Doctors failed to hand over properly between teams caring for the little girlHer death was 'avoidable'
Parents pay tribute to their 'energetic little girl'
20:00 GMT, 19 September 2012
A coroner accused staff at a top
London hospital of ‘gross failure’ today, following the death of a three-year-old girl in a paediatrics intensive care unit.
Isla Taylor was admitted to St
George’s Hospital in south London in June 2011 to undergo surgery to
repair her trachea, but died five days later from brain damage caused by
hypotension after days of low blood pressure which medics failed to
Westminster coroner Dr Fiona Wilcox
today said Isla’s death was ‘avoidable’ and that staff in the paediatric
intensive care unit (PICU) failed to give Isla ‘basic medical care’
that would have brought her low blood pressure under control and saved
Isla was born six weeks premature and had repeatedly contracted chest infections because of problems with her lungs
Delivering a narrative verdict Dr
Wilcox said: ‘The blood pressure was unacceptably low. Maintenance of
blood pressure, in my view, is basic medical care wherever you are.
‘It was a gross failure on the part of
the PICU staff not to do something effective to manage it. It was
unacceptably low for hour after hour on June 25 and 26. They should have
appreciated that it was low, their lack of appreciation in my view is a
Isla's parents paid tribute to their daughter. They said: 'She absolutely loved life'
She added: ‘I have found that the test
of neglect has in this narrow area on behalf of paediatric intensive
care unit staff has been met.’
Expert witness Dr Andrew Durward, a
consultant in paediatric intensive care at London’s Evelina children’s
hospital, said Isla’s doctors had been ‘blinkered’ into accepting low
blood pressure because of her complex medical history.
He said: ‘The complexity of this
patient almost blinkered the response in terms of accepting the low
numbers of blood pressure. It is a basic failure of medical care.
‘This patient had a blood pressure of
40 for days and that is unusual. I’ve never in my life seen anyone with a
blood pressure so low for so long in my 14 years as a consultant. You
can treat it so easily.’
Isla, from Twickenham in west London,
was born six weeks premature and had repeatedly contracted chest
infections because of problems with her lungs. she was admitted to the
hospital on June 23 for elective surgery on her airways.
But she was the victim of a catalogue
of errors which began when doctors inserted a breathing tube into her
mouth rather than her nose causing problems when she was sedated.
The tube was later moved to the wrong
part of her lung when vital information about her medical history was
not handed over to new doctors taking over her care, Westminster
Coroner’s Court heard.
Dr Caroline Davison, a consultant
paediatric anaesthetist in intensive care, said other doctors at the
hospital had ‘failed’ to tell her not to move Isla’s breathing tube
during the shift hand-over.
She said: ‘I think anything about an
airway that hasn’t been handed over would have been a serious failure.
It is not an ordinary failure, it is more than an ordinary failure. Bolt
and door it should have been handed over.’
Echoing this concern, Dr Wilcox said:
‘The failure of the anaesthetist to specifically hand over to PICU the
reason why the ET tube inserted at 14cm there was a gross failure in
care and this was a failure in basic medical care. It is something that
Dr Wilcox also found that antibiotics
should have been given to Isla earlier, and again branded the omission a
‘really serious failure’ given Isla’s propensity to contracting chest
Isla was due to undergo surgery to repair her trachea, but died five days later from brain damage
Robust new procedures to change the way patients like Islas are treated have been put in place at St Georges, the court heard
After three days in hospital Isla’s
condition deteriorated rapidly on June 26, her blood pressure could
barely be detected and she had to be resuscitated.
A CT scan taken the following morning
showed severe brain injuries which ‘shocked’ doctors treating the
patient. Isla died at 2.30pm the next day, on June 28.
Isla’s parents Stephen Taylor and
Nicola Roberts, who broke down in tears as they heard the verdict read
out, paid tribute to their ‘energetic little girl’ in a statement read
out in court.
They said: ‘Isla was a very energetic little girl, she absolutely loved life.
‘She had dropped all daytime naps and
there was no sign of any problems other than stated and her chest
infections was something the surgery was hopefully going to help.’
Robust new procedures to change the
way patients such as Isla are treated have been put in place at St
George’s, the court heard.
Dr Frances Elmslie, a consultant
clinical geneticist at St George’s who oversaw the changes, said today
that medics have to discuss the positioning of a patient’s tube if there
is a possibility they will go into intensive care, and that the level
of sedation has been reduced.
She said: ‘I feel happy that the process is now robust.’