Medics at a Leeds hospital missed several ‘windows of opportunity’ to correctly diagnose a teenage boy who died four days after being discharged.
Jacob Long, 15, of High Street, Rawdon, left Leeds General Infirmary (LGI) with ibuprofen and paracetamol for what was diagnosed as a respiratory tract infection on May 20, 2009.
He died four days later after suffering a tear in a major vein in his chest, Wakefield Coroner’s Court heard yesterday.
It is suspected that the tear was caused by a rare connective tissue disorder such as Marfan syndrome, which causes veins to rupture easily.
A report conducted by Dr Michael Ball, a consultant in intensive care and anaesthesia at Leeds General Infirmary, said: “There was a cumulative series of missed windows of opportunity.
“There was a collective failure by all the health care professionals at the emergency department to ask or identify the source of the symptoms.
“With early diagnosis and surgical intervention, this unfortunate death could have been avoided.”
The court heard Jacob had visited the minor injury unit at Wharfedale Hospital in Otley suffering from chest pains and a swelling in the neck.
He was then taken by blue light ambulance to Leeds General Infirmary where he wasn’t treated as urgent despite a GP, nurse and ambulance crew calling ahead to warn of his arrival and was discharged later that night.
A spokesperson for Leeds Teaching Hospitals NHS Trust said in the report: “The Trust wishes to express its heartfelt condolences to his family in the circumstances of the patient’s death from an extremely rare medical condition.
“Leeds Teaching Hospitals sincerely apologises to the patient’s family and friends for the shortcomings in his care which may have contributed to his death and hope that this report and the changes as a consequence of it will help them cope with their loss.”
The court was told several changes have since been made to the hospital’s procedures.
Dr Ball added that if Jacob had been admitted, further monitoring and investigations could have been carried out and he could have been treated more easily when the vessel in his chest ruptured four days later.
He explained that other ‘shortfalls’ included insufficient communication between doctors during handovers and the fact that Jacob was discharged without competent medical assessment and specific advice to the family.