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Woman died after Queen’s Hospital missed bowel obstruction


A 25-year-old girl died at her mother and father’ house after hospital employees failed to identify the bowel obstruction that killed her on an X-ray.

Juliet Saunders was admitted to Queen’s Hospital in Romford on March 7 final 12 months with belly pains and vomiting however was discharged after being wrongly identified with gastritis and died on March 9.

An inquest at Walthamstow Coroners’ Court held on April 30 heard the physician who noticed Ms Saunders displayed a “lack of scientific curiosity” and will have escalated her to a extra senior physician.

Ms Saunders suffered from a uncommon genetic situation, Cornelia De Lange syndrome, that made her extra susceptible to bowel issues. She was additionally severely studying disabled and “largely non-verbal”.

Her mother and father noticed she gave the impression to be in belly ache and vomited “a thick, deep yellow substance” on March 7. They referred to as 111, who requested an ambulance to take her to hospital.

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Summarising the proof he heard throughout the inquest, coroner Graeme Irvine mentioned: “I’ve been reminded that March 2020 was the very begin of the pandemic and that the emergency providers have been beneath some pressure.

“The registrar within the emergency division on the time was unfamiliar with the syndrome. She was a comparatively junior physician however, when offered with a affected person with a extremely uncommon and complicated historical past, didn’t switch duty to the ward’s marketing consultant.

“She arrived at a question prognosis of gastritis and pursued this prognosis, even when additional proof within the type of lab checks forged doubt upon its credibility.

“She mentioned she spoke to her supervising marketing consultant… and that he agreed together with her proposed plan of action however, within the absence of any proof, I’ve to deal with her account with some degree of scepticism.

“Fundamentally, this inquest has been hamstrung to some extent by the shortage of contemporaneous information. (The registrar’s) notekeeping was restricted to a single entry.”

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The lack of notes additionally meant there was “no clear proof” offered to the inquest that the physician truly regarded on the X-ray taken of Ms Saunders, though she informed the courtroom that she did.

Then-head marketing consultant Dr Akin Idowu informed the courtroom there have been three “clear indicators” of an obstruction on this X-ray, missed by the physician and later by one of many belief’s radiographers.

Ms Saunders was transferred within the afternoon to a different unit for observations with “no proof of scientific enter”, regardless of the hospital’s coverage stating a marketing consultant ought to have signed off it.

The observations unit didn’t make any notes on Ms Saunders and later discharged her with none examination or evaluate from a clinician.

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Mr Irvine famous that Barking, Havering and Redbridge University Hospitals NHS Trust, which runs Queens, accepted there have been “failures in care” however argued they might not be thought of “gross” failures as a result of Ms Saunders was such a posh affected person.

Mr Irvine rejected this argument, including: “The belief’s failures led to Juliet not being admitted to hospital. Had she been admitted for energetic monitoring, there would most likely have been a chance… to save lots of her life.

“The belief allowed Juliet and her household to go away hospital with out… recommendation on what to do if she deteriorated and it appears to me this should be essentially the most merciless side of the case. I really feel positive they’d have taken these steps admirably.”

He added that he anticipated the belief to refer the registrar concerned in Ms Saunders’ care to the General Medical Council and would so himself if it failed to take action.

He concluded the inquest with the discovering that Juliet died of “pure causes, contributed to by neglect”.

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