Neglect contributed to the death of a young girl from complications arising from meningitis, an inquest has found.
After hearing four-and-a-half days of evidence jurors took just under two hours to find that the death in 2013 of seven-year-old Kate Pierce, of Chester Road, Rossett, was of a natural cause to which neglect had contributed.
Kate was nine months old on March 29, 2006, when she was referred to Wrexham Maelor Hospital by an out-of-hours GP, having been vomiting and “presenting with green mucus”.
She was assessed by Dr Halenahalli Vijayakumar, a junior doctor on the children’s ward at the time, who noticed her enlarged and inflamed tonsils.
He misdiagnosed her with viral tonsillitis and she was discharged at about midnight.
A day later she was taken back to the Maelor and diagnosed with pneumococcal meningitis and rushed to Alder Hey Children’s Hospital in Liverpool.
Although her life was saved, Kate was left with brain injuries that left her needing round-the-clock care until she died in her sleep during a family holiday to Florida six years later.
On the night she was first taken to the Maelor her parents, Mark and Diane Pierce, had asked for second opinion after feeling uncertain about Dr Vijayakumar’s initial diagnosis of tonsillitis.
He assured them he would get one and returned within ‘about’ 45 minutes to say he had spoken to his “boss” and Kate was fine to be discharged.
Giving evidence earlier in the hearing Dr Vijayakumar, now a GP in Leeswood, Flintshire, said he had no recollection of the night of March 29, meeting Kate’s parents or the conversation he had with registrar Dr Sarah Piper.
When Dr Piper gave her evidence she also said she could not recall the night or talking with Dr Vijayakumar about Kate, but that did not mean no conversation took place.
But there was no record at all of any conversation and it would have been Dr Vijayakumar’s responsibility to make a written note of it.
Jurors also heard that Kate’s parents’ had always contended she was “asleep” while the assessment by Dr Vijayakumar took place, something the jury members were asked by the coroner to consider.
The final day of the inquest began with evidence from London-based impartial expert witness Dr Simon Nadel.
Looking at the evidence he said it was “likely” the morning of March 31 was the first time Kate showed signs of having meningitis, but she would have needed to have been started on intravenous antibiotics 12 hours earlier to “prevent the outcome” she suffered.
The earlier she received antibiotics, the more chance of lessening the serious affects of meningitis.
Before the jury members retired to consider their conclusion David Lewis, deputy coroner North East Wales and Central, asked them to consider a number of questions.
They included whether Kate had been assessed “sufficiently”, whether on the balance of probability Dr Vijayakumar had consulted with the registrar Dr Piper, and whether the discharge plan had been fully understood by, and explained to, her parents.
The jury returned with a unanimous narrative conclusion that Kate died of a natural cause to which neglect had contributed.
Her parents, who were present for every day of the hearing in Abergele, shed tears on hearing the conclusion.
Mr Lewis praised them and said he was “humbled” at the way they had conducted themselves with “dignity” throughout the process.
A spokesman for the couple said they would not be making any comment at this stage.
A spokesman for Betsi Cadwaladr University Health Board said later: “We accept the jury’s findings in this rare and tragic case and we would like to offer our sincere condolences to Kate’s family.
“There were aspects of the care Kate received in 2006 that fell below an acceptable standard and once again we would like to offer our sincere apologies to her family.”
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