Source · Prevention of Future Deaths

Isabel Gentry

Ref: 2017-0111 Date: 6 Apr 2017 Coroner: Maria Voison Area: Avon Responses identified: 0 / 4 View PDF

The deceased's death from meningitis B could have been prevented by vaccination, highlighting an ongoing risk if the teenage group, which is at increased risk, is not included in the vaccination program.

Date 6 Apr 2017
56-day deadline 2 Jun 2017
Responses identified 0 of 4
Child Death (from 2015) Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary
The deceased's death from meningitis B could have been prevented by vaccination, highlighting an ongoing risk if the teenage group, which is at increased risk, is not included in the vaccination program.
View full coroner's concerns
_ Evidence was provided during the inquest that if Isabel had received the meningitis B vaccination that her death would have been prevented; There is therefore an ongoing risk that future deaths will occur unless action is taken in relation to extending the vaccination program to include the teenage group which is at increased risk:

Report sections

Investigation and inquest
On 24th May 2016 commenced an investigation into the death of Isabel Lily GENTRY Aged 16_ The investigation concluded at the end of the inquest on 17in March 2017. The conclusion of the inquest was that the medical cause of death should be recorded la) Group B meningococcal meningitis Box 3 read as follows: Isabel Gentry had meningitis, she became IIl on 17th 2016 her 'symptoms included: headache all but worse in the evening; neck pain; a fever; shivering; vomiting, muscular pain, dizziness and she had fainted once; she had loose stools for 3 days. The paramedic that examined her considered that she may have sepsis as part of his differential diagnosis. Isabel was taken to hospital. The doctor did not take an accurate history or a full history and did not reach a differential diagnosis which should have included sepsis and SIRS. The observations and the bloods taken were not normal: The diagnosis of viral gastroenteritis was not accurate: The vital signs were not considered in the light of the fluid and medication she had received. The previous case of meningitis was not acted upon: There was no senior review. Isabel was discharged on the morning of 18th May. During that she became more unwell Isabel was taken back to the Bristol Royal Infirmary that evening was treated but her condition deteriorated and she died on 2Oth May 2016_ Way May day day

The conclusion as to the death based on all the evidence was recorded as Natural causes contributed to by neglect
Circumstances of the death
The circumstances were recorded in Box 3 which are reflected above. In summary Isabel Gentry became ill with meningitis on 17lh 2016. She attended the Bristol Royal Infirmary and was discharged on 18"h May with a diagnosis of viral gastroenteritis _ As the she became more unwell and was readmitted to the Bristol Royal Infirmary on 'rogresedhatebeningeThordiagnoellsaod meningadmiteconfire Bdistd Rogay despite appropriate care and treatment her condition deteriorated and she died on 20" May 2016_
Action should be taken
In my opinion action should be taken to prevent future deaths and believe you have the power to take such action
Inquest conclusion
Isabel Gentry had meningitis, she became IIl on 17th 2016 her 'symptoms included: headache all but worse in the evening; neck pain; a fever; shivering; vomiting, muscular pain, dizziness and she had fainted once; she had loose stools for 3 days. The paramedic that examined her considered that she may have sepsis as part of his differential diagnosis. Isabel was taken to hospital. The doctor did not take an accurate history or a full history and did not reach a differential diagnosis which should have included sepsis and SIRS. The observations and the bloods taken were not normal: The diagnosis of viral gastroenteritis was not accurate: The vital signs were not considered in the light of the fluid and medication she had received. The previous case of meningitis was not acted upon: There was no senior review. Isabel was discharged on the morning of 18th May. During that she became more unwell Isabel was taken back to the Bristol Royal Infirmary that evening was treated but her condition deteriorated and she died on 2Oth May 2016_ Way May day day

The conclusion as to the death based on all the evidence was recorded as Natural causes contributed to by neglect

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Report details

Reference
2017-0111
Date of report
6 April 2017
Coroner
Maria Voison
Coroner area
Avon

Responses identified

Responses identified 0 of 4
4 responses not yet linked

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 2 Jun 2017.

Sent to

Committee of Vaccination and Immunisation
Department of Health and Social Care
John Ratcliffe Hospital
Oxford University

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