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Saturday, 04 July 2015

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Heather’s tragic death sparks hospital changes

MAJOR changes have been made at the West Cumberland Hospital after the death of 14-year-old Whitehaven girl Heather Thackaberry.

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tributes: Heather Thackaberry

By Staff Reporter

Heather died on the operating table in July 2012 during surgery for suspected appendicitis after surgeons found a large abscess in her lower abdomen. She went on to suffer a cardiac arrest.

An inquest this week heard the cause of her death was septicemia, peritonitis and acute inflammation of the fallopian tubes.

Coroner David Roberts recorded the following verdict: "Heather died at the conclusion of abdominal surgery as a result of a previously undiagnosed but natural infection of her fallopian tubes."

Simon Raimes, who led an 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 investigation found: “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.”

It recommended:

  • The paediatric ward must consider the use of age-appropriate medical early warning charts;
  • Paediatric life-support training must be undertaken by all appropriate personnel;
  • The anaesthetic and surgical departments need to agree a protocol for out-of-hours operating;
  • 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;
  • Guidelines should be written to ensure the admitting consultant is made aware when severe deterioration occurs so 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 how Heather’s parents, Alex and Sonya, had 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 that when they suggested other possible causes of Heather’s pain, such as cysts, they were dismissed.

Their daughter was taking painkillers regularly and was in a lot of pain. Other concerns were raised such as why blood tests, which revealed Heather’s body was responding to inflammation, were not taken earlier, and a lack of communication with hospital staff while Heather was having surgery.

The teen attended the Cumbria Health on Call (CHOC) service on June 27 and was diagnosed by Dr Michael Lewis as having a urinary tract infection for which she was given antibiotics. She was advised to continue taking medicine to relieve constipation.

She also sought an emergency appointment with GP Dr Judith Spencer, at the Catherine Street surgery in Whitehaven, on June 29 and was diagnosed as being constipated, having an ongoing UTI and an umbilical hernia. Heather was prescribed other medication for constipation and told to continue the treatment for the infection.

Mrs Thackaberry contacted CHOC on June 30 saying her daughter had “pain in her right side and she was crying with it”. Heather was later admitted to the children’s ward at West Cumberland Hospital.

An assessment was carried out by Dr Korim Shafeek. He said: “My working diagnosis was constipation but I did not rule out other causes.”

Heather was prescribed a suppository and laxatives, which did not work. Tests showed she had high respiration and high heart rate, which Dr Shafeek attributed to pain. Blood tests were carried out and a surgical review concluded it was most likely Heather had an appendicitis.

The family was informed of Heather’s death 50 minutes after she died.

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.

Mrs Thackaberry said of her daughter: “Heather was a character in every way. She always preferred the underdog.

“If you were down, Heather was the first person to try and cheer you up and make you laugh. She was the confidante of the family, but she was also a typical teenage girl – stuck to her mobile and trying to sneak out to school with make up on. We were very close – everywhere I went, she came too.

“I should be helping her to revise for her GCSEs now, not sitting through her inquest.”


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