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Coroner warns over sharing of key medical data after death of 3 year old boy

A coroner has sent a letter to the Department of Health following the death of a 3 year old boy who died when crucial medical details were ignored.

Moné White died on 7th July 2012 at Northwick Park Hospital from acute heart failure

27 February 2014

A coroner has sent a letter to the Department of Health (DoH) suggesting a new system of sharing crucial medical details within all Trusts in the UK.

The regulation 28 letter follows the inquest into the death of a 3-year-old boy at Northwick Park hospital in July 2012.

Coroner Andrew Walker heard how notes from medical experts, within Moné White’s medical records, were not read and specialist medical care, which the coroner concluded was likely to have saved the boy’s life, was not provided.

Giving a narrative verdict at North London Coroner’s Court at the end of the inquest on 17th January 2014, Mr Walker told the court that he was sending the letter to the DoH as he was so concerned that future deaths will occur unless action is taken.

Mr Walker sent the letter to the DoH on 24th January 2014 asking them to consider: “The development of a flag system for patients, under the care of specialist hospitals, with special clinical requirements to ensure that advice about clinical care is brought to the attention of all treating clinicians.”

Moné White died on 7th July 2012 at Northwick Park Hospital from acute heart failure and suffered from Dilated Cardiomyopathy, a disease of the heart muscle.

Moné was born at St Mary’s Hospital, Paddington, on 25th March 2009 with dilated cardiomyopathy, caused by a viral infection. The condition cannot be corrected by surgery and whilst Moné’s cardiac function gradually recovered, it never returned to normal.

For the first 3 years of his life Moné was kept under review by the Royal Brompton Hospital, and was seen by the Cardiology team there.

Over the next couple of years Moné attended several Accident and Emergency departments at various hospitals near to his North London home.

As a result of his history of rapid deterioration and cardiac arrest a plan was agreed between the Cardiologist at the Royal Brompton Hospital and other medical professionals including local paediatricians, London ambulance service and Moné’s parents.

It detailed that a call to the Ambulance Service would require a mandatory response and Moné would be taken to the nearest Accident & Emergency, who would be presented with a one page summary of his significant problem and a suggested approach to managing him as an extreme emergency.

An emergency treatment plan was therefore prepared by the Royal Brompton Hospital on 8th August 2010, to be distributed between all those caring for Moné.

It provided clear guidance to all those who came into contact with Moné, to ensure prompt and timely access to the correct care, and to ensure that they consulted with the Royal Brompton Hospital whenever concerns about Moné arose.

A copy of the document was sent to Northwick Park Hospital and circulated to the pediatricians there, and Moné’s parents were also given a copy to inform local teams about his condition and fragility. A copy of the document was also inserted in Moné’s medical notes.

On the morning of 5th July 2012 Moné’s father called an ambulance, due to concerns about Moné’s condition. He was taken to Northwick Park Hospital by ambulance.

The inquest heard how the emergency treatment plan was not seen by any of the doctors at the hospital and that there was no evidence that a Consultant ever attended Moné on 5th July 2012 and Moné remained their overnight.

On the morning of 7th July 2012 when Moné’s mum raised concerns at 10.15am no action was taken and doctors failed to act quickly enough to diagnose his heart failure.

In his narrative verdict Andrew Walker said: “On 7th July 2012 Moné’s condition was stable at the time of the ward round in the morning but had deteriorated by 10.50. Doctors attended and began to treat Moné but they wrongly confused his condition with low blood sugar and administered Glucose.

"Shortly before 11.25 Moné became unresponsive and despite attempts it was not possible to save his life."

Mr Walker went on to say: "If Moné had been referred and been accepted by the Royal Brompton on the 5th or 6th July 2012 it is likely that he would not have died when he did."

Suzanne White from law firm Leigh Day who is representing the family said:

“The treatment of this very poorly little boy should have been so much better than it was. We welcome the steps taken by the Coroner to try and prevent this ever happening again in any hospital in the UK.

“The doctors responsible for Moné’s care at the Royal Brompton had gone to great lengths to ensure that he was treated appropriately. The fact that these measures, detailed in an emergency treatment plan, remained unseen over the three days Moné was in Northwick Park Hospital is truly shocking.”

Moné’s family have created an online E-Petition, which asks the Government to look into the need for specialist hospitals to have an A&E service for known vulnerable children with high-risk special requirements like Moné. 

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

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