Girl, 3, died from low blood pressure after hospital doctors failed to give her 'basic medical care', says coroner
Isla's blood pressure was 'unacceptably low', finds coronerDoctors failed to hand over properly between teams caring for the little girl
Parents pay tribute to 'energetic little girl'
16:12 GMT, 19 September 2012
A three-year-old's death could have been avoided if medics at her children's intensive care unit had given her basic medical care, a coroner said today.
Isla Taylor was admitted to St
George’s Hospital in south London in June 2011 to undergo
surgery to repair her trachea. She died five days later from brain
damage caused by hypotension after medics failed to spot her low blood pressure.
Westminster coroner Dr Fiona Wilcox accused the staff of 'gross failure' and said basic care would have brought her blood pressure under control and saved her life.
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 gross failure.'
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.
Isla's parents paid tribute to their daughter. They said: 'She absolutely loved life'
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 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 handover to PICU the reason why the ET tube inserted at 14 cm there was a gross failure in care and this was a failure in basic medical care. It is something that was critical.'
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 infections.
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 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
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 like Isla’s 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 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.'