Evelyn Smith

The investigation into the death of Evelyn Mary Smith concluded at the end of the inquestl on September 2014. The cause of her death was Acute Ulcerativel Laryngotracheobronchitis; the conclusion of the inquest was narrative (copy attached).

Miss Smith was 7 years old at the time of her death on 13 September 2013. She did not have significant past medical history The illness which resulted in her death began on 11 September 2013. She awoke in the early hours of 12 September with difficulty in breathing: This prompted her mother to take her to the Accident Emergency (A&E) Department at Warwick Hospital (part of South Warwickshire NHS Foundation Trust) . She was seen by a Foundation Year 2 (FY2) doctor who had 8 weeks undergraduate and nd postgraduate experience in paediatrics_ This doctor diagnosed Miss Smith as having 'viral] croup' and prescribed steroid medicine (Dexamethasone). Miss Smith was discharged after the FY2 doctor discussed her case with a more senior 'Specialty A&E Registrar' Both doctors were reassured that her vital signs were improving, although she did have persisting fever and a heart rate above the normal range. Later on the 12 September 2013 Miss Smith's family arranged for her to be reviewed at hers GP practice because of ongoing concerns She was seen by an Advanced Nurse Practitioner , who diagnosed tonsillitis and prescribed antibiotics_ Her respiratory rate , along with other vital signs, were not documented as part of this consultation. On 13 September 2013 Miss Smith remained unwell and was taken back to her GP_ She was seen by a doctor who again diagnosed viral croup. Her GP accessed a 'clinical mentor' tool on the practice computer system, which highlighted scoring algorithm to classify the severity of croup. Miss Smith was scored as having moderate croup which, the scoring classification suggests, warranted admission to hospital However; after treatment with a Salbutamol nebuliser (instituted because of a recent insect sting) Miss Smith's_GP_ felt_that_she_had improved and_prescribed a further_course of oral steroidl and medication (Prednisolone) . She was not admitted to hospital and returned home Whilst at home later on 13 September, Miss Smith suffered an acute deterioration in her breathing, at which point she had cardiac arrest _ Despite the institution of early resuscitation and rapid transfer to hospital by paramedics, it was not possible to revive her and she was pronounced dead at Warwick Hospital. A post-mortem examination demonstrated the presence of a virus (Parainfluenza Virus Type 2) and a bacterium (Staphylococcus Aureus) as infectious organisms, which resulted in Acute Ulcerative Laryngotracheobronchitis.

In my pinion, consideration should be given as to whether action is required to prevent future deaths_ believe the addressee has the power to make such a consideration take appropriate action.