How Leeds hospital missed chances to save desperately ill boy - Coroner

A TEENAGE boy who died from a haemorrhage four days after he had been sent home from Leeds General Infirmary with painkillers could have been saved if he had been admitted as an inpatient, a coroner said today.

Jacob Long, 15, from Rawdon, in Leeds, died in May 2009 after a vein near his heart ruptured, possibly as a result of an undetected genetic syndrome.

He was sent to the Leeds 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.

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

Mr Hinchliff said there were a “number of missed opportunities and failures” after Jacob arrived 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 coroner said: “Leeds is the largest teaching hospital in England. Leeds, I am told, is the second largest city in the country. An institution of that size ought to have permanent consultant cover in its accident and emergency department.”

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Mr Hinchliff told the inquest how Jacob went to the minor injuries unit at Wharfedale General Hospital, in Otley, on 20 May 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 had low blood pressure.

A doctor at the hospital made a diagnosis of bleeding in the chest and arranged for Jacob 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 Jacob arrived at the LGI, Mr Hinchliff said there were a “cumulative series of missed windows of opportunity”.

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He said these included Jacob not being prioritised when he reached the hospital; being prescribed painkillers by a junior doctor without medical review; and only having one further blood pressure check at the hospital.

Mr Hinchliff said Jacob was “inappropriately discharged without competent medical assessment” despite abnormalities being identified on an electrocardiogram and an X-ray.

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 21 May.

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

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He died from a spontaneous rupture to a vein near his heart, resulting in haemorrhage.

Mr Hinchliff said the cause was “highly suggestive of an underlying connective tissue disorder arising from an undetermined genetic abnormality”, such as Marfan syndrome.

The coroner said there was a “collective failure by healthcare professionals” and “serious individual shortcomings”.

He described the death as “rare” and “tragic” and said that doctors were not expected to have reached a precise diagnosis.

However, he said admission to hospital was likely to have identified the haemorrhage and the source of the bleed and corrective surgery could have been undertaken.