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News Coroner's Inquests 16th Feb 2015

Lewis Close Inquest – if only they had listened!

A Coroner today criticised a series of doctors who failed to refer a 14 year old boy to hospital after he had returned to England after undergoing an emergency operation for a perforated appendix whilst on holiday in Turkey.

Lewis Close (14) died of multi-organ failure in October 2013 caused by sepsis three weeks after eventually being admitted to hospital. By then experts agreed that it was too late to save him. His parents had consulted medical professional on 9 occasions in the 9 days after his return to England but in spite of the parents’ concerns none of the doctors realised the seriousness of his condition.

Speaking on behalf of the family after the inquest verdict, solicitor Paul Balen said:

“Lewis’s distraught parents consulted GPs, 111 and the Primary Care 24 hour clinic but lack of knowledge of sepsis and failure to take basic observations obscured the medical practitioners’ judgments until it was too late. They simply did not listen to the parents who knew their child best.”

“Deaths from sepsis after an appendectomy should be regarded as a “never event” added Mr Balen.

Only 2 years ago the Prime Minister, David Cameron, speaking after the publication of a damning Ombudsman’s report following the death from sepsis of a 3 year old boy, said:  “it is absolutely shocking and saddening to see a whole succession of health services fail this family and anyone who has lost a child that young knows how harrowing and dreadful this experience is”. In that case (Sam Morrish) the child’s MP Anne Marie Morris told Mr Cameron in the House of Commons “this must not happen again”.

It has!

The Nottinghamshire Coroner, Mairin Casey highlighted 5 missed opportunities doctors had to save Lewis’s life but heard that major changes had already been made since his death. She said that she would append them to her judgment in the hope that they would become essential guidance imported into the minds and practices of all medical practitioners.

Giving evidence at the inquest, intensive care specialist Patrick Davies who fought valiantly to save Lewis once he had been admitted to the Queens Medical Centre in Nottingham, said that he believed doctors should adopt a mantra that if a patient presented with the same concern 3 times, whatever the doctor had originally thought he should now consider alternatives and that doctors should learn to accept that parents, who knew their children better than anybody, may well be right. The Coroner commended this 3 strike rule which Lewis’s family hope will ensure that no more children die of undiagnosed sepsis.

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