The death of a teenager from a severe stomach infection at Heartlands hospital should never have happened, the chief executive said yesterday.
Dr Mark Goldman apologised to the family of 15-year-old Sian Jones, who died after developing peritonitis in August 2007 as he revealed the case had prompted a raft of changes in the way the hospital deals with patients.
The teenager from Stirchley was admitted to the hospital with stomach pain but developed the infection and died on a ward at the hospital a week later.
At an inquest into her death in Sutton Coldfield yesterday, Dr Goldman said: “I wanted to say how deeply sorry everyone at the trust is about the outcome of Sian’s care at the trust. This is a death that shouldn’t have happened.”
The director of surgery at the hospital, Misra Badhoo, who carried out an investigation following Sian’s death, said there was a failure to recognise the early warning signs and the hospital did not act quickly enough.
He said: “Early warning signs of sepsis were not recognised or acted on in a timely manner.
“Assessment from medical staff from the 10th of August did not recognise that tests showed an acutely ill child. There was a failing to recognise it,” he said.
Mr Badhoo – a general surgeon at the hospital who specialises in colorectal surgery – said her death was entirely avoidable and that it should have been avoided.
“I think everyone that’s involved in this case – whether it be a junior or senior doctor or nurse – absolutely regrets this happening.
“It’s very difficult for anyone involved in this case to say how it got to this stage. I don’t think anyone could say why it did. But I think everyone is totally sorry and apologises. As individuals and as a group everyone is very regretful that this did happen.”
Sian was admitted to hospital on Monday August 6, 2007 with pain in her abdomen, she was given surgery two days later to remove her appendix but by Thursday she had developed an infection leading to death from peritonitis.
Mr Misra estimated that her chances of survival would have been 75 to 85 per cent if the infection had been picked up by doctors and treated on Thursday.
By the time the infection was spotted and she went in to surgery on the Saturday he said her chances of survival stood at only five per cent. She died the following Monday of multiple organ failure.
Dr Goldman said the case had prompted a raft of changes at the hospital including a new way of recording patients’ notes, better communications between staff members at different levels and changes to the way the hospitals were staffed at weekends.
He also said there would be more cover by consultants to act as an “extra pair of hands” when hospitals were busy, particularly during out-of-hours times at Heartlands including weekends and evenings.
Other changes included improvements to notes, changes to policies for paging doctors and changes to ward rounds to ensure patients had better access to consultants.
Dr Goldman also said that everyone who was involved with the case had been involved in meetings with other staff members or one-to-one meetings to discuss Sian’s care and where the system failed her.
The inquest continues.