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Damning verdict at inquest into death of 2-year-old from treatable brain condition

Coroner verdict confirms that death of 2-year-old Alice Mason was avoidable after a serious brain condition was left undiagnosed and untreated by doctors

14 October 2013

A Coroner has given a damning verdict at the end of an inquest into the ‘avoidable’ death of a 2-year-old child who died after a brain condition was left undiagnosed and untreated.

In a narrative verdict, coroner Dr Sean Cummings confirmed that a ‘large number of serious failures’ in the care of Alice Mason had led to her death.

The inquest at West London Coroner's Court heard that Alice had successfully undergone treatment for a brain tumour two months before she was taken ill with hydrocephalus - or ‘water on the brain’ in March 2011.

Dr Cummings said that Alice had died "prematurely" at home on March 31 2011 from her illness, which had gone "undiagnosed and untreated".

Alice’s care was shared between her family's local district general hospital, Kingston Hospital in Surrey, cancer specialists at the Royal Marsden Hospital, in Chelsea, west London, and a neurosurgical team at St George's Hospital, south London.

Dr Cummings said: "What I continue to have concerns about is the ability of the consultants to effectively lead their teams."

After the inquest Alice’s parents Rosalind and Gareth said: “Our daughter’s death at two years of age, which the coroner has today described as ‘avoidable’ has devastated us.

“She died in pain whilst under the care of medical professionals in whom we had placed our trust and who we were forced to beg to get her the help she needed.

“Expert evidence has made clear that if the doctors had done what they should, Alice would be with us today.

“The inquest has clearly shown that despite Alice being under the ‘shared care’ of three hospitals, these hospitals did not work together as they should.

“We are grateful that the Inquest into Alice’s death has at last allowed us to hear from the medical staff involved in Alice’s care and heard how an abject failure of leadership led to our daughter’s untimely death.

“The evidence has been shocking and should cause concern for all those who are patients of shared care systems across the UK.

“We would like to know what has been done and being done to ensure nothing like this ever happens to another family.

“We hope the serious concerns the coroner will now communicate to all parties, including the CQC and NHS London, will lead to a real change in the way care is provided to children in London and across the UK.

Nicola Wainwright from Leigh Day, the law firm representing Alice’s parents, said: “The evidence the Coroner heard at the inquest has confirmed the numerous failings in Alice’s care.

“The lack of responsibility taken by the Consultants and the complete lack of communication of vital information about Alice’s condition between and within teams was just astonishing.

“We will continue to pursue legal action against those involved.”

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