‘Chances missed’ in toddler’s death
Thursday 10th October 2013, 5:40PM BST.
The mother of a toddler who died after doctors failed to spot her fatal brain condition in time to save her launched an attack today on “shared care” between hospitals.
Two-year-old Alice Mason had successfully undergone treatment for a brain tumour two months before she was taken ill in March 2011.
She died days later, having developed fluid on the brain, an inquest at West London Coroner’s Court has heard.
The youngster’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.
Today the child’s mother, Rosalind Mason, told the inquest: “I’m still not convinced that shared care is a safe option for providing care to very sick children, and I’m afraid our experience of even trying to learn the truth about our daughter has been hugely complicated.”
She said this involved communicating with the different hospitals and added: “We have found that going through the reports they have written in answer to our questions has been very lengthy, and we have not agreed with many of the things they have written, and asked them to correct them. It’s saddening that this situation is in place.”
Mrs Mason and her husband Gareth claim that a catalogue of chances to act on their daughter’s symptoms were missed.
The inquest has heard that the parents were told at the Royal Marsden on March 23, 2011 that an MRI scan had shown some signs of fluid accumulation and Alice should be taken to Kingston Hospital if her symptoms worsened for a CT scan.
But by the time tests were carried out, Alice had suffered irreversible brain damage, caused by hydrocephalus, or “water on the brain”, and emergency surgery could not save her.
Lawyers for the family claim there were also further delays in transferring Alice to St George’s Hospital and in the surgery taking place. She died at home on March 31 2011.
Mrs Mason said the parents took Alice to Kingston Hospital on the evening of March 23.
“Her symptoms were worsening, she was more sick, it was evening, and we felt that she needed medical attention,” she said.
“They just said they would try another drug to control the vomiting.”
As time went by she asked a doctor why they were not having a scan, and the doctor said they did not “fulfil the criteria”.
Mrs Mason added: “I felt that I wasn’t being properly listened to.”
She kept a note of how often her daughter was vomiting because she was not convinced hospital staff were keeping all the records of it.
Expert witness Dr Stephen Rose, a consultant paediatrician at Birmingham Heartlands Hospital, confirmed that he had said in a report into the case that it was unclear why a CT scan was not undertaken on the 24th and 25th, as then she would have been taken to St George’s straight away as a medical emergency.
Asked by the family’s lawyer Jeremy Hyam whether he had said that death, as of the 26th, was avoidable, he said: “That is my opinion.”
Dr Rose told the inquest that it might be “a little bit foolhardy” to dismiss parents’ fears that there has been a deterioration, adding: “Why wouldn’t you do a scan? You have a situation where there has been a change. You’ve got to explain the problem. If you can’t explain it, you have to investigate it in order to explain it.”
The inquest has heard that Professor Martin Gore, medical director of the Royal Marsden, who led an inquiry into Alice’s care at the hospital and Kingston Hospital following her death, found more than a dozen failings by medical staff.
Coroner Dr Sean Cummings has said the report had shown failures at “almost every pathway” of care given to the toddler including unclear information about her MRI scan, inadequate communication, lack of overall care plan, lack of monitoring of her hydrocephalus and a failure to listen to Alice’s parents.
Dr Cummings said he would hear submissions in the case tomorrow and he planned to deliver a narrative verdict on Monday afternoon, at a time to be confirmed.