Hospital criticised over errors before death of boy, 15

David Hinchliff heard Jacob Long, 15, left Leeds General Infirmary with ibuprofen and paracetamol for what was diagnosed as a chest infection but he collapsed and died four days later .

The teenager, from Rawdon, in Leeds, died in May 2009 after a vein near his heart ruptured, possibly as a result of undiagnosed Marfan Syndrome – which causes problems with connective tissues and blood vessels.

He had been sent to the Leeds General Infirmary (LGI) after suffering from a sudden pain in his chest and a swelling in his neck the size of half a tennis ball but was later discharged.

Recording a narrative verdict at Wakefield Coroner’s Court yesterday, coroner David Hinchliff said: “Had Jacob been an inpatient at the time of his catastrophic bleed on May 25 2009, his chances of successful resuscitation and survival would have been greater.”

Mr Hinchliff said there were a “number of missed opportunities and failures” at the LGI and he made a recommendation to the Leeds Teaching Hospitals NHS Trust that a consultant should be permanently on duty in the accident and emergency department of the hospital.

The inquest heard how Jacob went to the minor injuries unit at Wharfedale General Hospital, in Otley, on May 20 2009 after coughing and experiencing pain in his neck and chest. He had a large, black swelling to the right side of his neck, measuring 15cm by 10cm and low blood pressure.

A doctor made a diagnosis of bleeding in the chest and arranged for him to be transferred to the LGI by emergency ambulance, informing a registrar there of his impending arrival and his concerns about his condition.

But after his arrival, Mr Hinchliff said there were a “cumulative series of missed windows of opportunity”, including Jacob not being prioritised; being prescribed painkillers by a junior doctor without medical review; and only having one further blood pressure check.

Mr Hinchliff said Jacob was “inappropriately discharged without competent medical assessment”.

Jacob and his grandfather, who was with him at the hospital, were also not given any advice about symptoms to look out for after he was discharged on May 21.

Four days later, the teenager collapsed at his grandparents’ home and was rushed to the LGI, where he was pronounced dead.

Mr Hinchliff said there was a “collective failure by healthcare professionals” and “serious individual shortcomings” and told Jacob’s grandfather: “I offer you and your family my belated condolences. I am very sorry that you lost Jacob in this way. I am sorry that you are in this situation.”

A spokesman for Leeds Teaching Hospitals NHS Trust said: “The Trust fully accepts the coroner’s verdict, which accords with the findings of our own very detailed internal investigation into all the circumstances of this very sad incident.”