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Inquest into tragic death of two-year-old child from Harlow hears of “substandard” treatment at Princess Alexandra Hospital

Health / Tue 19th Mar 2024 at 08:18am

AN INQUEST into the circumstances surrounding the tragic death of a two-year-old child from Harlow took place on Monday in Chelmsford.

Photos supplied by family.

Ivy Amaya Rupasinghe, was just two years old, when she died in the Paediatric Intensive Care Unit (PICU) on October 19th, 2022 at Addenbrookes Hospital in Cambridge.

After the inquest, Ivy’s parents Kelum Rupasinghe and Thuy Lam said that the medical authorities “missed opportunities to help Ivy”.

PAHT admitted that its care was “substandard”

The coroner, Lincoln Brookes gave a narrative conclusion. He said the cause of death was multi-organ failure, caused by Epstein Barr Virus infection Glandular Fever).

Where a short form conclusion is not enough, the coroner or jury will outline more descriptive factual findings in a narrative conclusion

The inquest was opened by senior coroner, Lincoln Brookes, who explained to all present, how inquests work and what conclusions it may come to.

Ivy’s parents, Kelum and Thuy were present. As were legal and medical representatives from Princess Alexandra Hospital Trust (PAHT).

The morning session began with details from the post mortem.

This was followed by a statement from Dr Imran Gohar of Sydenham House Surgery on Monkswick Road in Harlow.

The court heard that Ivy was taken to the surgery by her parents on October 6th with a high fever. Dr Gohar advised the parents to give her Calpol. He also advised that if the condition worsened, they should take Ivy to A and E at Princess Alexandra Hospital (PAH).

On Saturday October 8th, Ivy’s condition worsened and so her parents took her to PAH. After a wait of several hours, she was seen by a Dr Kareem.

They arrived at 1.30pm and left at 1030pm. Ivy was seen by a number of peopl intermittently but in the end, she was treated for Tonsillitis.

They left having been given antibiotics.

Dr Kareem did not give evidence, in fact the court was told that he was not able to be traced.

On Sunday October 9th, Ivy’s condition got worse and so her parents took her to PAH. But as they entered the car park area, Ivy went into cardiac arrest.

After she was resuscitated and further treatment and assessment given and undertaken, Ivy was transferred to the PICU at Addenbrookes in Cambridge.

Over the next week, Ivy’s condition worsened and worsened. On October 19th, her life support was removed and she passed away.

The cause of death was given as: “child died due to hypoxic ischaemic brain injury secondary to cardiac arrest secondary to sepsis”.

The only person to give evidence in person in the morning session was Dr Nicola Ray from PAH. Dr Ray was not present at the time but came with a prepared statement and was duly available to be questioned by the coroner and the family’s legal representative.

Dr Ray gave a time line of the events that occurred from when Ivy was taken to PAH on the Saturday until she was transferred to Addenbrookes.

Much of her evidence detailed the events that took place on Saturday October 8th and Sunday October 9th in PAH.

At this point, Mr Brookes asked a series of questions centred on “what should have happened….with the benefit of hindsight?”

Dr Ray told the court that blood tests should have taken place and that ultimately, Ivy should have been kept in hospital.

This led to the question from Mr Brookes: “If Ivy had been kept in, would there have been a different outcome?”

Much of the evidence and questions centred around the respiratory illness, Epstein Barr Virus. In the post mortem, there was evidence of this in a number of Ivy’s organs.

The question seemed to be if this had been picked up through blood and other tests, what would happened?

Dr Ray said that in her opinion “the outcome would have been the same”.

Later she said that in eighteen years, she had only seen one case similar to Ivy.

Dr Ray did regret that the treatment on that Saturday was not better.

It should be noted that Dr Ray extended her wholehearted sympathy to the family.

At this point, the family’s legal representative, Mr Barker asked a number of questions.

He told the court that he had an independent expert who believed that Epstein Barr Virus (EBV) was not the cause of death.

In the afternoon, consultant paediatrician Edwin Haworth gave evidence. He again, expressed his deepest sympathies to Ivy’s parents. He told them they had been through a horrendous ordeal.

He told the court that it had been a very busy day in the department but that Ivy should never have been sent home from the hospital. He told her there was no penicillin in the hospital.

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6 Comments for Inquest into tragic death of two-year-old child from Harlow hears of “substandard” treatment at Princess Alexandra Hospital:

Adam
2024-03-19 13:21:54

I am so sorry, the NHS is just appalling and PAH is terrible. Close down the NHS and reform it, the staff care more about the NHS than they do the patients. Why can he DR not be traced? Why was there no penicillin in the hospital ? This will continue until people start demanding the NHS delivers for the 200+B a year we give it, stop putting it on a pedestal, stop clapping for it, stop giving it more money, it is not idolised around the world it is a laughing stock. Demand it provides the service we pay for.

Alex
2024-03-19 14:47:55

What a ridiculous response from Adam. I feel so sorry for this family. But the nhs saves lives everyday of the week. In the last 15 yrs I've had 2 major operations that certainly saved mine. Procedures that i wouldnt have been able to afford in USA. As a pensioner the cost of private health insurance would be exorbitant. Its a sad truth that there will always be mistakes made but scrapping the nhs is not the answer. Proper funding and better training is the key.

Keeley
2024-03-19 15:18:45

That poor family, so sad. Maybe if the local GP picked up on how poorly she was in the first place and started antibiotics then maybe have been different, dr gohar was the dr who told my auntie she had a throat infection and the cough was all in her head, this went back and forth for weeks then we later found out she had lung cancer and died. He then told me I don’t need to be referred after irregular bleeding and a history of cervical cancer, I then put it in writing that if he didn’t refer me and something was wrong I’d sue. I was later referred as he wouldnt sign my letter and I later had an emergency hysterectomy but remember dr gohar said that there was no need to be referred. I have now moved from harlow and my local gp is so much better. If your dr is him, I would get away if you want to have a healthy happy life. We did put in a complaint that took months to be seen and other gp covered for him saying it was all protocol and his a good doctor, they will stick by eachother instead of pushing crap doctors for extra training or to be watched to make sure they actually do the job properly.

Adam
2024-03-19 16:15:30

Alex why do you assume the only alternative is the US system which is equally crazy. There are many systems across the world in Europe and US/NZ etc which are much better than the NHS. They are easier to access and have better outcomes the sad reality is most people are convinced it is NHS or US system. I would advocate we align with those. The NHS needs to be scrapped because it is not fit for purpose it has not been for decades.

Mrs Black
2024-03-20 14:20:33

Firstly my heart goes out to the parents of little Ivy. This is difficult for me to write because I was a qualified Nurse (now retired) who did my training at PAH and it was such a special place back then. I personally feel that while A&E needed extending to accommodate the growth of Harlow and surrounding areas they didn't pay enough attention to certain staff members who had a god complex. Because of one particular female staff member we lost my brother. By the time he got the care he needed he was already on a downward spiral and when I made an official complaint she had falsified records and had others write pages of notes that never happened. There is so much more but she was not got rid of but moved sideways. The NHS is what it is but PAH needs to focus on some of the Nursing staff and their lack of ability to carry out the job they chose to do. Nurses play a pivotal role in the treatment of patients and to liaise with the Drs and to give the best and safest care possible. This in my opinion has not been a priority at PAH for too many years. They need leaders, not just more staff. The fact that they can't trace a Dr doesn't surprise me in the least.

Caroline Smith
2024-04-19 18:34:43

My brother In law died in a&e in pah on 25th march 2023 after being left for 15 hours with chest pain jaw pain and arm pain. He had an ecg on arrival which showed a myocardial infarction ( heart attack ) at 3 in the afternoon and blood test wasn’t taken until 8pm the results came back without the important traponin levels so retest was done the results came back at 1.10 am under 35 was ok his levels were 535 he had a massive heart attack he was left on his own and found unresponsive and blue and all evidence points to falsifying the time line he died at 4.41am at the inquest on Tuesday 16th April the dr admitted they failed him abysmally. That hospital is getting worse. The coroner said there was a delay of 10 hours where he could have been taken to the cardiotherasic unit at Basildon where the outcome may or may not have been the same. However at least if they had done this at least they would of followed protocol and it would of been easier to accept my sister and her family are devastated as her husband was only 57 and all majors were taken up by the frail. With that in hindsight why can they not have a&e for specific problems like an OAP a&e a drug and drunk tank and a separate a&e for mental health. Instead they are building a 600million pound hospital for a car park because residents at the one we have won’t let pah have a multi story car park. They could pump that money into the one we have and make it so much better

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