Coroner troubled at missed chance to treat girl

Ten-year-old Dena Hale was found unresponsive by her mother Debbie on the morning of March 3, 2011, an inquest was told.

Despite her father Stephen performing CPR and the efforts of paramedics at their home in Altofts, near Wakefield, Dena was pronounced dead at Pinderfields Hospital that morning.

The Wakefield inquest heard Dena had been to her GP surgery with slurred speech and pins and needles in August 2009.

The locum doctor wrote that he thought she was dehydrated, adding “refer to specialist” – but this referral never happened, which coroner David Hinchliff called a “missed opportunity”.

Her regular GP at the Newland surgery, Dr Ram Prasad Gupta, was also unable to understand a memo the locum wrote on Dena’s notes – “CSOS” – which another doctor translated as “See in an emergency”. Mr Hinchliff noted that Dena had been seen by a specialist after visiting A&E in January 2010 when her parents said she had suffered a fit. But she had not been diagnosed with epilepsy or put on any medication.

He noted that she had been given an electroencephalogram (EEG), used to pick up electrical activity in the brain, when awake but not one when she was asleep.

When she was reviewed a year later, it was found that she had not had any more episodes.

Professor Judith Cross, an expert witness, said Dena could have suffered benign epilepsy with centrotemporal spikes, which occurs in children after the age of five and usually stops at 14.

Asked by the coroner whether the GP should have referred Dena to a specialist after she visited in August 2009, Prof Cross said yes, but she also agreed that GPs were not specialists and could not be expected to know every symptom of every condition.

Recording a verdict of death by natural causes caused by sudden and unexplained death in epilepsy, Mr Hinchliff said: “I’m very conscious that Dena has showed symptoms of likely neurological problems in the form of 
epilepsy.

“She was seen by her GP on more than one occasion. I think that there were indications there that would have been appropriate for her to be referred to the appropriate clinicians with expertise both in paediatrics and epilepsy for her to have been reviewed and followed up.

“Had that been the case then based on the fact that there were at least two events that were suggestive of some epileptic activity some diagnosis could have been made.

“Then, assuming this, there would have been a discussion about treatment and options.

“Whether that would have been putting Dena on some kind of medication would have been discussed.

“I strongly suspect that Dena’s parents would have had reassurance if there had been a positive diagnosis, and been a discussion of options.

“As part of that a sleep EEG should have been performed. Whether that would have been diagnostically helpful can only be guessed.

“I’m troubled by the records of the GP, in particular when the locum doctor has made reference to a referral that did not happen. I would regard that as a missed opportunity.”

But Mr Hinchliff said that Dena may not have been saved even if she had been diagnosed and given medication.

Speaking after the inquest, Dena’s mother Debbie, 37, said: “We’ve been through hell since Dena died and we’re still going through it.

“Dena was a lovely, friendly girl who lit up a room when she walked into it. If she saw anyone upset she wanted to make it better.

“The coroner talked about missed opportunities but the biggest missed opportunity is 
Dena’s missed opportunities – she should have been at high 
school now, playing with her friends, spending time with her family.

“We tried so many times to get answers – but no-one would listen to us. I would say to other parents: don’t rest until you have an answer. Get a second, a third, a fourth opinion if you have to – don’t give up. The inquest hasn’t answered many of our questions; it’s just given us lots more.”

The family said questions had arisen as to whether Dena would still be alive “if appropriate action had been taken”.

Switalskis Solicitors said a claim for medical negligence would be pursued by the family.