Hospital failed to spot brain condition in teenager, who died six days later
Staff at Antrim Area Hospital failed to recognise a serious brain condition in a teenager that contributed to her death, an inquest has heard.
Shauna Marie Shivers from Castledawson died in 2009 after being taken to hospital suffering from vomiting and dizziness.
The 15-year-old, who had diabetes, was admitted on November 29 with a condition called diabetic keto-acidosis (DKA), but died six days later.
However, within hours of being admitted, staff had failed to spot that she had also developed acute cerebral oedema – a swelling of the brain.
She was also complaining from a headache, which staff believed was caused by dehydration.
The medical staff used an adult protocol to treat the teenager, instead of a paediatric protocol designed for children aged 18 and under. Within an hour after her admission, she was put on an intravenous drip and given paracetamol. Despite showing symptoms linked to a cerebral oedema, this was not treated.
Her condition deteriorated and she was moved to the intensive care unit, where she died on December 2.
An expert, Dr Paul Jackson, told Coroner Suzanne Anderson excess fluid administered via a drip 'probably' did have a part to play in her death.
A damning report written by Dr Jackson, from the Royal Victoria Hospital for Sick Children, highlighted a number of failings in her treatment. These included:
* Using an adult protocol despite her being 15-years-old;
* No clear documentation plan;
* A delay in taking advice of consultant on-call;
* Written records were poor;
* Medical staff should have spotted problems linked to a possible cerebral oedema by 4pm.
Dr Jackson also explained a paediatric guideline provides more detail in addressing fluid levels and volumes. Another difference is the clarification of direction it gives to medical staff.
DKA is a common complication of diabetes, when the blood sugar levels are no longer under safe control and the blood becomes too acidic. If left unchecked, DKA can lead to a coma or death.
Yesterday at the Belfast inquest, both the trust and its medical director apologised to the Shivers family. An action plan has since been implemented to address the failings highlighted in the report.
A letter from the Chief Medical Office was also sent to every trust in Northern Ireland highlighting learning issues.
Ms Anderson recorded the cause of death as acute cerebral oedema and diabetic keto-acidosis. Offering the family her deepest sympathy, she said hopefully the action taken by the trust would mean "no other family having to endure the same tragedy".
Oedema is the build-up of fluid and causes affected tissue to become swollen. The swelling can occur in one particular part of the body. When a patient has cerebral oedema, there is more fluid in the skull than there should be. This causes the brain to swell, which has a number of consequences. The swelling can compromise the brain's blood-flow. Cerebral Oedema that affects the brain is an unpredictable complication of children diagnosed with diabetic keto-acidosis (DKA).