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Tuesday, 21 October 2014

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Dad of girl who died during surgery says doctors didn’t listen

A grieving father says he is disappointed with the outcome of an inquest into his 14-year-old daughter’s death.

Heather Thackaberry photo
Heather Thackaberry

Related: Cumbrian hospital changes its routines after death of girl, 14

A three-day inquest was held for Heather Thackaberry, who died on an operating table at Whitehaven’s West Cumberland Hospital on July 1, 2012. She had complained of abdominal pains the previous week.

Coroner David Roberts returned a narrative verdict, saying: “Heather died at the conclusion of abdominal surgery as a result of a previously undiagnosed but natural infection of her fallopian tubes.”

However, following the inquest, Heather’s father Alex Thackaberry, said: “We felt that the doctors didn’t listen to us and we are disappointed with the coroner’s verdict.”

The inquest heard that in the week before she died, the Whitehaven teen was diagnosed by two GPs as having a urinary tract infection.

She was admitted to the hospital on June 30. While having an operation for suspected appendicitis surgeons found a large abscess in her lower abdomen. They carried out surgery but she later suffered a cardiac arrest.

The inquest heard that Heather’s parents, Alex and Sonya, have raised numerous concerns about their daughter’s care.

In his conclusion, Mr Roberts said: “Heather died of overwhelming sepsis due to salpingitis, an infection which it is likely had developed symptomatically over the preceding months. This condition had not been diagnosed by her attending clinicians. Stronger antibiotics could have been administered earlier than they were but it is not possible to say this would have altered the outcome.”

He highlighted a Sudden Untoward Incident (SUI) investigation which was carried out after Heather’s death 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: “This 14-year-old girl died as a result of overwhelming systemic sepsis, the severity of which was not recognised until the latter part of the operation. The source of the sepsis was a pelvic abscess and this was probably not due to appendicitis.”

It added: “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 report said “lessons could be learned”.

Five recommendations about observations, paediatrics life support, sepsis guides, antibiotics guides, out-of-hours settings and input by consultants were raised.

These have either been implemented or are near completion.

Mr Roberts said he was satisfied that recommendations were made, through the SUI report, and were carried out.

Speaking after the inquest, Mr Thackaberry said: “I can see that some changes have been made and take some comfort from the fact that these have been made directly as a result of Heather’s death.

“I hope that if someone like Heather walks into that hospital today they will be treated differently.”

Sonya described her daughter as “bright” and “a social girl” who had aspirations to become a vet. She said Heather had matured into a “lovely young lady” and said the family will “never recover from her loss”.

Heather attended Howgill Nursery before going to St Gregory and St Patrick’s School. She then attended St Begh’s School before studying at St Benedict’s.

  • After the inquest, Dr Jeremy Rushmer, medical director at North Cumbria University Hospitals NHS Trust, said: “We would like to extend our sincere sympathies to Heather’s family at this very sad time and for their tragic loss in 2012.

“We carried out a full internal investigation following Heather’s unexpected death and, in this exceptional case, we also requested an independent external investigation.

“Although both confirmed that the tragic outcome for Heather was unlikely to have been any different due to the speed and severity of her sepsis, they did identify concerns with the management of her care which the trust has taken very seriously.

“We have taken significant steps since 2012 to learn from this case and make improvements in our hospitals including the launch of an awareness campaign for our staff about how to spot and treat the early signs of sepsis.

“We have now addressed all of the recommendations arising out of the internal and external investigations to ensure the highest possible standards of patient safety.”

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