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Saturday, 25 October 2014

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Cumbrian hospital changes its routines after death of girl, 14

Major changes to healthcare have been made at Whitehaven’s hospital after the death of a 14-year-old girl.

Heather Thackaberry photo
Heather Thackaberry

Related: Family demands answers after Cumbrian girl, 14, dies during surgery

Heather Thackaberry, of Whitehaven, died on an operating table at the West Cumberland Hospital on July 1, 2012. The teen was having an operation for suspected appendicitis when surgeons found a large abscess in her lower abdomen, an inquest has heard.

Surgeons carried out surgery but she suffered a cardiac arrest.

The cause of her death was septicemia, peritonitis and acute and chronic salpingitis – inflammation of the fallopian tubes.

Simon Raimes, who led a Sudden Untoward Incident (SUI) investigation after Heather’s death, told the inquest: “The death of any patient is very rare. The loss of a child in these circumstances is extremely unusual.”

The SUI aimed to find out problems that occurred and to see how the North Cumbria University Hospital Trust, which runs the hospital, can learn from it.

The report stated: “We have not found any single event that led to Heather’s death. We have found a number of factors that need to be addressed to try to optimise the recognition and management of potentially sick children in the out-of-hours setting.”

The five recommendations were:

n The paediatric ward must consider the use of age-appropriate medical early warning observation charts;

n Paediatric life support training must be undertaken by all appropriate personnel involved in the care of sick children;

n The anaesthetic and surgical departments need to agree a protocol for out-of-hours operating in line with the national CEPOD and RCS recommendations;

n Management of systemic sepsis guidelines and antibiotic guidelines for abdominal and systemic sepsis are to be available in an easily seen location in every operating theatre;

n Guidelines should be written to ensure the admitting consultant is made aware when severe deterioration occurs so that support can be provided for families and staff.

Some of the recommendations have been implemented while others are being put into place.

The inquest heard that Heather’s parents, Alex and Sonya Thackaberry, had numerous concerns about their daughter’s care in the week before she died. They questioned the medical practitioner’s early diagnosis of Heather as being constipated and having a urinary tract infection.

They said when they suggested other possible causes of Heather’s pain, such as cysts, they were dismissed.

They said even though their daughter was taking painkillers regularly, she was in a lot of pain. They described her as “clammy”, “shaking” and “white”.

Other concerns were raised such as why blood tests, which revealed Heather’s body was responding to inflammation, were not taken earlier, the sequence of events and a lack of communication with hospital staff while Heather was having surgery.

The family was informed of Heather’s death 50 minutes after the time of her death was recorded.

Dr Muhammad Sohail, speaking at the inquest, described Heather as “a brave girl”.

He said Heather was initially going to have keyhole surgery but when they started the procedure they found a large abscess.

A gynaecology surgeon was contacted but after Heather’s wounds were closed, she collapsed. CPR was carried out but medical staff were unable to save her.

The inquest continues.

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