Two-year-old Tharun Umashankar had been admitted to Sheffield Children’s Hospital and died from bleeding of the stomach lining which was probably caused by his intolerance to milk, an inquest heard.
Independent expert Dr David Crabbe, a paediatric surgeon said an endoscopy would have found the bleeding and Tharun could have had an operation that day which would have saved him.
He told the Sheffield inquest: “What was a complete failure was the lack of collaboration between surgeons and gastro-enterologists. Closer teamwork would have resulted in a different outcome.”
Tharun’s distraught mother Sentamil, 38, who lived in Barnsley at the time but now lives in London, broke down in tears as she told the hearing: “I believed they would cure him and make him well.”
The boy had endured three endoscopies at the hospital in the previous fortnight after vomiting blood and suffering severe stomach pain, but was thought well enough to be discharged on Friday, July 9, 2010.
But during the night he fell ill again and was rushed by ambulance to Barnsley Hospital before being transferred to the Children’s Hospital unit on the afternoon of Saturday, July 10.
Consultant gastro-enterologist Dr David Campbell, who was in overall charge of Tharun although off duty that weekend, said he left instructions to be called if the boy had a serious bleed again.
But that did not happen, and despite “panicked” attempts by medics, Tharun failed to respond and he died at 9am on the Sunday.
Paediatric registrar Dr Tafadzwa Makaya, whose job was to stabilise the boy, told the inquest she had not been informed of any “red button plan” to alert Dr Campbell if there was a further bleed. Dr Crabbe, who reviewed the case, said Tharun had a “mighty strange illness” for a child and he had not come across such a case of catastrophic upper gastro-intestinal bleeding in a youngster before.
He said the boy should have had an endoscopy on the Saturday which was an “error of judgment” by the doctors caring for him.
“The benefits of identifying the cause of the bleeding far outweigh the potential risks,” he said. “I would say Dr Campbell was taking a risk.”
The inquest was adjourned.