Doctors missed chances to treat Corsham brain tumour girl, inquest told (From The Wiltshire Gazette and Herald)
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Doctors missed chances to treat Corsham brain tumour girl, inquest told
A 16-year-old Corsham girl died after doctors missed several chances to treat a killer brain condition, an inquest heard today.
Student Diana Moore, from Broadmead, Corsham, had suffered on and off from headaches, nausea, light-headedness and slurred speech for a couple of years before being operated on in 2005.
The teenager was then also admitted to Bristol's Frenchay Hospital in April 2006 with hydrocephalus, water on the brain, but after four days in hospital was sent home for the weekend.
She returned the following Monday but to her mother Deborah's shock, she was discharged by doctors 24 hours later.
A senior consultant admitted today that he had made a "bad call" in sending Miss Moore home when he did.
When the teenager took a turn for the worse four days later, Mrs Moore called the hospital for advice on how to treat her daughter.
Later that day, after Miss Moore's condition got dramatically worse, an ambulance took her back to Frenchay Hospital.
But the Bristol hearing was told that due to a "miscommunication", an external drain that should have been fitted as soon as Miss Moore arrived was not set up for another two hours.
"Diana didn't want to be ill. She was a person who wanted to get on with life. She was absolutely terrified of her condition," Mrs Moore said.
The inquest at Flax Bourton Coroner's Court, near Bristol, was told that the teenager had been admitted on April 18, 2006 for four days after suffering the seizure which had affected her speech and one side of her face.
During this time doctors monitored the intracranial pressure in her brain and despite "spikes" of almost double what would be normal, she was discharged by consultant paediatric neurosurgeon Michael Carter the following day.
"To my surprise, Mr Carter discharged Diana," said Mrs Moore.
The mother, who also lost her eldest daughter to cot death and her husband to a tumour in 1993, added: "I was absolutely taken aback by this. I was shocked when Mr Carter on April 25 said he was going to discharge her. I asked him on three occasions if he was sure about this.
"I thought: somebody can't go from having seizures to then just having nothing done. But anyway, she was discharged."
The following Saturday Miss Moore took a turn for the worse, having woken up with a headache.
After ringing the Barbara Russell Children's Unit at Frenchay Hospital, Mrs Moore treated her daughter with paracetamol.
She said at the inquest that she went out to get some stronger painkillers but her daughter's condition continued to deteriorate.
"Diana was screaming in agony on my bed saying that she felt her head was going to burst and actually that was the last coherent word my daughter said to me," Mrs Moore said.
"She was the most awful grey colour. I called the ambulance. I just called 999 because I was just so frightened.
"I can't emphasise the way Diana looked at that time. I honestly thought she was dying right there and then."
When the ambulance arrived there was discussion about which hospital the teenager should be taken to.
The Royal United Hospital in Bath was closer to her home in Corsham, but it was decided Miss Moore should return to Frenchay for specialist treatment.
By this time Mrs Moore said her daughter had lost the ability to co-ordinate her legs.
"It looked as though they were dragging her into the ambulance," she said.
"It was one of the most horrific things I have ever seen."
On arrival at the hospital a medical team was waiting for them and Miss Moore, who by this time was semi-conscious, was sent for a CAT scan.
Mrs Moore added: "I couldn't communicate with her. How much I wish for one last conversation with my daughter, but it didn't happen.
"I kept trying to talk to her and I begged her to stay with me, to stay with me."
While at the hospital Miss Moore's breathing became slow and a crash team was called for before she was operated on.
"I had an intuitive feeling my daughter was dying," Mrs Moore said.
"I asked the team and they said: No, no, no. But I was fixated on this and asked again and they said: No, we're experts in this field and we've caught it in time. They said they were going to put her onto a breathing machine that would help her to breathe. When I asked why, they said to help her rest as tomorrow she was going to have a shunt fitted."
After reassurance from the nurses that her daughter would be fine Mrs Moore went to sleep at the hospital but was woken by staff at sunrise on April 30.
"She (a nurse) said: Please wake up, your daughter is dying. I just could not believe what I was hearing," she said.
"One minute I was being told she would be okay. Now they were telling me she was dying.
"Eventually the medical team started talking about her being dead. It was difficult as she was breathing but that was because she was on the life support.
"Mr Carter was telling me: We don't know how she died or why she died."
The inquest heard Miss Moore was "brain-stem dead".
Despite requesting a post-mortem examination, Mrs Moore was told it was not needed.
She was then approached about donating her daughter's organs, which she thought her daughter would have wanted and eventually agreed to, but told the hearing she did not realise this would make a post-mortem examination impossible.
It was another three years before Mrs Moore was told a mistake had been made with her daughter's treatment.
"Nobody told me a mistake had been made. No one told me until July 17 2009 when the trust admitted civil liability but made it clear in no uncertain terms they would not go into any more detail," she said.
Mr Carter told the hearing he had not realised the full extent of the teenager's condition at the time due to poor record keeping and the fact he was verbally briefed on her condition rather than thoroughly looking through the records.
"I think what it comes down to is things were quite a lot worse than I appreciated," the consultant said.
He added that Miss Moore had attended the hospital during a "transitional" phase when medical details were commonly passed among staff verbally as it was moving to a computerised system.
"At the end of the day the information was there, I just didn't pick it up," he said.
"I formed the impression things were getting better when they were not. Subsequently, when I went through the records I was horrified.
"One struggles to work out how I came to this conclusion at that time.
"The point was, during Diana's admission she seemed very well. I thought things were probably improving rather than getting worse.
"I decided to make the call to let her go. I did not do this lightly. I did this with the full knowledge that I had.
"I made a bad call."
He also admitted the staff had been "on the hop" and were trying to deal with a "huge" number of patients.
Mr Carter said in retrospect he would have pushed for a shunt to be inserted at an earlier stage.
"I think if she had had a shunt, it is unlikely she would have deteriorated in the way she did," he said.
When Miss Moore was readmitted on April 29 a volume of fluid was drained from her brain and she showed a slight improvement, the hearing was told.
Mr Carter was not on the ward that night but in a "courtesy call" he was told an external drainage system was set up and that Miss Moore was due to have the shunt fitted the next day.
But the consultant told the inquest the drainage system was in fact not set up for some time due to a "misunderstanding".
Mr Carter said: "It should have been set up as soon as she came through the door. It was not set up for another two to three hours."
He added: "I think it is very significant. She was at that point salvageable. I think the drain would have made the difference."
The inquest, due to last for four days, was adjourned until tomorrow.