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Coroner criticises lack of communication at Oxford hospital

Amie Oliver died at Oxford’s Nuffield Orthopaedic Centre on 2 May 2009

Amie Oliver

24 May 2010

Alison Millar, a partner specialising in clinical negligence and human rights at Leigh Day & Co, recently represented the family of Amie Oliver, a young woman who died at Oxford’s Nuffield Orthopaedic Centre (NOC) on 2 May 2009, at the inquest into her death that was held at Oxfordshire Coroner’s Court on 10 May 2010.  Amie suffered from a rare and complex medical condition called Mucolipidosis that meant that when she died her stature was approximately that typical of a five - six year old child.


Mucolipidosis is one of a group of rare metabolic illnesses that are characterised by the abnormal accumulation of waste products of metabolism in various bodily tissues and organs.

Amie’s death

Although Amie was only a month past her 18th birthday, and her medical needs continued to be much more like those of a child than an adult, Amie was admitted into an adult ward at the Nuffield Orthopaedic Centre (NOC) in Oxford on 29 April 2009.  She was suffering severe pain in her right leg, and also had a fever. Over the next two days Amie developed increasing breathing difficulties, such that she required increasing amounts of oxygen to breathe, and on the evening of 2 May 2009 she was complaining of chest pain.  By that time she was gravely ill.  It took some three hours for a doctor to attend on her, despite several calls from the nurses.  Amie suffered a heart attack whilst waiting for the senior doctor on call to review her.  She was transferred to the nearby John Radcliffe Infirmary, where, unlike at the NOC, critical care facilities are available, but sadly could not be revived. 

At the inquest into her death Nicholas Gardiner, the Oxfordshire Coroner, said that doctors at the NOC should have contacted one of the national specialist centres that are commissioned nationally to provide care round the clock for patients with Mucolipidosis and related conditions.  The Coroner returned a verdict that Amie’s symptoms were not fully considered in the context of a patient suffering from Mucolipidosis and there was ignorance of specialist help that was available.

Delays and lack of communication

Throughout her daughter’s time in hospital Amie’s mother told the clinical staff to contact Amie’s consultant specialist in Manchester for advice on managing her condition which they failed to do. There were delays by nursing staff to recognise Amie’s deteriorating medical condition, and the situation was further hampered by a lack of appropriate paediatric equipment so that nurses could not accurately measure her vital signs.  There were only two doctors at the hospital on the night of 2 May for up to 90 patients and they had to deal with another patient who also died that evening.  The Coroner said that bleeps were not promptly responded to which may have been a reflection of lack of staff over that bank holiday weekend.

Amie’s parents were supported by the Society for Mucopolysaccharide Diseases (the MPS Society) throughout the inquest.  Christine Lavery, Chief Executive of the Society said:
“It appears that clinical staff were ignorant of the existence of National Specialist Commissioned centres of expertise for Lysosomal Storage Diseases and chose to ignore Amie’s mother’s repeated requests to contact her consultant specialist.  We believe the circumstances surrounding Amie’s death are of grave concern and may even have been avoidable.”

Alison Millar, who continues to represent Amie’s family in a potential human rights claim, said:

 “Amie’s death raises both training and systems issues at Nuffield Orthopaedic Centre, with regards to monitoring patients, communication between staff and the operation of equipment.  But more importantly, listening to patients and relations - if the medical team had contacted her supervising specialist they would have been advised on how to manage her symptoms which may have saved Amie’s life or ensured she died with dignity with her parents present.  This was something Amie and her family were denied.”

Leigh Day & Co has many years experience in representing families and people with disabilities who have received substandard, inadequate or inappropriate care from health, education and social services. For more information please contact Alison Millar on 020 7650 1200.

Information was correct at time of publishing. See terms and conditions for further details.

Information was correct at time of publishing. See terms and conditions for further details.

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