The heartbroken parents of a teenage girl who died following a series of blunders by the Royal Stoke University Hospital say their devastating loss was “completely avoidable”. An inquest into the death of 15-year-old Isla Mae Hudson, from Whiston, heard there were “significant care quality issues”.
Her parents Claire and Richard Hudson told the hearing in Stafford that their daughter was given “incorrect and inadequate treatment” by the hospital and that her death has been a “horrendous ordeal” for the family. Isla, who was born with myotonic dystrophy and had learning difficulties, died in the early hours of September 13, 2023, having been taken to A&E with severe stomach pains two days prior.
The inquest heard that there were costly delays in her undergoing a vital CT scan, a “gung-ho” approach to the administration of morphine despite its impact on her breathing due to myotonic dystrophy, a failure to carry out examinations, a lack of observations, and poor fluid maintenance. The hearing was also told that a “perfect storm” of her condition, dehydration, acidosis, colonic ischemia, a twisted bowel, and the effects of the morphine ultimately led to her becoming unresponsive.
In a statement read out by the coroner, her parents said she had suffered with intermittent stomach pains for around 12 to 18 months but they had been able to manage it. However, having been in A&E two weeks prior, Isla and her family returned to the hospital due to the severity of her pain.
They said: “We thought we were taking her to the safest place in the world. Thirty nine hours with doctors and her short life was over. How could that be possible? Losing Isla was a disaster for our family. We will never recover. There is a hole in our family that will always be there.”
At the hospital, Isla came under the care of consultant colorectal surgeon Dr David Luke who told the inquest he was “shocked and hugely upset” when he was informed of the teenager’s death. He added: “I have regrets. Isla was young and I have two children. We recognise some weaknesses in the system. We think the separation between the surgery and paediatric teams is a weakness that collectively we’re trying to address.
“I regret the outcome. I’ve thought long and hard about what we would do differently. The plan wouldn’t be different, she clearly needed a CT scan. My biggest regret is the timeline – getting tests done. I think it may have altered the outcome. If we had the report on the morning of the 12th the chances are we may have been able to do something that day. As it was she waited another 12 hours.”
Consultant paediatrician Dr Sean Monaghan said there were “system failings in Isla’s care” and told her family that he was “extremely sorry”. He added: “It had a negative impact on Isla’s care and outcome. If she had the care she should have had it would have given her a significantly better chance of survival.”
Giving evidence at the inquest was Consultant Paediatrician Dr Caroline Groves, the University Hospitals of North Midlands NHS Trust’s designated doctor for child death, who carried out the subsequent investigation into Isla’s death. She highlighted a number of failings on the part of the hospital – with a total of 36 recommendations made in her report for the Royals Stoke to act on.
The hearing was told that Isla’s oxygen saturation levels dropped after receiving her first dose of morphine in the emergency department (ED), but there was no written documentation of this or that she needed to be prescribed oxygen following a fresh dose.
Crucially, despite a “very experienced” doctor in ED requesting a CT scan, it was declined because they didn’t have the title “consultant”. Dr Groves said this was an “error” and prevented the likelihood of the scan being carried out in the emergency department.
The scan was further delayed due to protocol stating that a pregnancy test needed to be carried out. Given Isla’s learning disability, her family were dismayed at this and evidence was heard during the inquest that a consultant would have been able to “override” this. Her parents were also angry that Isla had been verbally referred to as “non-compliant” when they felt she had always dealt well with examinations.
Further failings included delays in giving fluids, Isla’s weight not being taken at any point, and the fact that she was given the top dose of morphine when it should have been administered with the least amount and then gradually increased if necessary. Dr Groves described the approach as “gung-ho”.
The inquest was told that after the CT scan was eventually carried out on September 12, when the report was sent to Dr Luke it is not clear if it included the addendum detailing the possible twisted bowel or was missed by him because of a large gap in the report due to the formatting. The inquest also heard it was wrongly flagged up as “urgent” rather than “critical”.
Doctors working on the night shift were aware of the findings, having been informed by the radiologist consultant, but this was not relayed to Dr Luke. Isla was also not assessed in the early hours prior to her death despite the nursing team being “concerned about the pain she was in”, the inquest heard.
Following a post-mortem, paediatric pathologist, professor Marta Cohen gave a cause of death of colonic ischemia caused by myotonic dystrophy. However, Dr Groves believes that given the evidence that has emerged in her investigation that morphine was also a cause of death. Dr Cohen does not consider it an “immediate cause” but would accept it being listed as “a contributory factor”.
The inquest was adjourned until a later date to allow the coroner to consider the evidence and speak further with Dr Cohen regarding the cause of death. He told the inquest: “I need time to reflect on what I’ve heard before I make any findings of fact. Clearly concerns have been raised about the standard of care. I will have to give thought if I include finding of neglect and if I need to issue a report for prevention of future deaths.”
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