Gross failure led to Twickenham toddler's death
8:00am Saturday 22nd September 2012 in News By Rachel Bishop
“Serious failures” by staff at a south London hospital could have contributed to the death of a three-year-old girl, a coroner’s court has heard.
Isla Taylor, from Twickenham, died at St George’s Hospital, Tooting, on June 28, last year, following elective surgery on her trachea.
The toddler, who was born with a congenital heart condition, was admitted to the hospital on June 23, but died five days later.
Expert witness and consultant in paediatric intensive care Dr Andrew Dudward described a number of serious failures.
Isla was given a graft on her trachea, and a breathing tube was fitted in her throat.
Dr Dudward said doctors were setting themselves up to fail from the start by inserting the tube orally, rather than nasally, because it would be more likely to be disrupted.
Fearing she may damage the graft if she were able to move about, staff felt it would be best to give her sedatives – using a mixture of four drugs, including morphine.
The court heard how the incorrect placement of the breathing tube created the foundations of a chest infection. Sepsis can lead to hypotension.
The exact cause of Isla’s death was not known, but it was believed her prolonged low blood pressure may have caused brain damage, resulting in multiple organ failure and ultimately her death. Sedation can also lower blood pressure.
Dr Martin Gray saw Isla on June 28 and carried out a brain scan. He said he was shocked when he saw the level of brain damage Isla had suffered, making him believe there were unexplained factors contributing to her death.
Dr Dudward said he believed her prolonged low blood pressure would have had more of an effect on her due to her heart condition, causing her serious brain damage. He said the failure to manage her blood pressure correctly was a “failure of basic medical care.”
On Monday, September 17, at Westminster Coroner’s Court, doctors said in retrospect they would have acted differently.
Coroner Dr Fiona Wilcox said: “The blood pressure was unacceptably low. Maintenance of blood pressure, in my view, is basic medical care.
“It was a gross failure on the part of the PICU (paediatric intensive care unit) staff not to do something effective to manage it.”
The hospital has improved several systems since Isla’s death, including an improved handover system, changes in communication and changes to sedation procedures.
