Fatal appendicitis misdiagnosed by hospital as stomach bug, inquest told
THE parents of a five-year-old who died at home from a burst appendix after being wrongly diagnosed in hospital with a bad stomach bug had not been given sufficient advice by doctors when they took her home, an inquest was told.
Speaking at the hearing into the death of Elspeth Moore, of Highfield Avenue in Lymington, West Hampshire Coroner Graham Short said that although the diagnosis had not been unreasonable, medics should have informed her mum and dad of the signs to look out for that would indicate she needed to be brought back to Southampton General Hospital.
The inquest in Winchester was told that Elspeth had been suffering from vomiting and diarrhoea when she was referred to the hospital’s pediatric unit by her GP on 3rd July last year, having been sick 10 days before.
Mr and Mrs Moore had put this down to the summer heatwave.
A week later, Elspeth was lethargic, and as the weekend progressed she complained her stomach was hurting.
On Monday 25th June she went to school as normal, but her mum was later called to collect Elspeth as she had diarrhoea. The next day, Mrs Moore took her daughter to her GP, who referred her to pediatric unit as she was dehydrated and had a high temperature.
Mr Moore joined them there. He said: “As Elspeth often did, she was putting a brave face on things – but I could tell she wasn't her bright, effervescent self.” She complained her stomach felt like it was “on fire”.
Elspeth was seen by a Band 3 healthcare assistant, who was not a registered nurse, before being examined by consultant paediatrician Dr Faye Hawkins, who diagnosed gastroenteritis.
Mr and Mrs Moore were told to give her 5ml of water every five minutes to see if she could keep it down, which they did for around an hour.
Mr Moore told the court that by this time it was around 8pm. Elspeth was very sleepy but had not been given a bed, so he approached Dr Hawkins to ask how best to proceed.
He said: “The message we were given was that if we were happy to go, we could. Given that when we arrived we were freaking out, for want of a better word, to be told she had a virus, I felt quite relieved and happy to go, based on that.”
'We felt optimistic'
He added: “We were told we could always come back, but we weren't given specific advice on when to come back or things to look out for.”
The following day Elspeth seemed to be improving and Mr Moore said: “We felt optimistic, she was starting to come out of it.”
On 5th July however, Elspeth was sick again and could not keep anything down, but Mr Moore said he and his wife felt confident that this was simply the virus leaving her system.
At 11pm that evening Elspeth was still awake in her bed. Mr Moore recalled: “I said, ‘I love you’, and she said, ‘I love you daddy’ and we turned off the lights.
“I heard a weird noise like something was catching in her throat and I asked her if she wanted to sit up, but she didn't respond.”
Despite attempts at CPR by Mr Moore and then, after an ambulance was called, paramedics and hospital staff, she was pronounced dead at Southampton General Hospital just after midnight.
Consultant paediatric pathologist Dr Darren Fowler, who carried out the post-mortem examination, said Elspeth was suffering peritonitis, which he described as an “overwhelming infection” after her appendix had burst.
Sepsis developed as her body’s defence system went into overdrive.
The inquest heard how abnormal positioning of Elspeth’s appendix may have put pressure on her bowel, causing diarrhoea, instead of the peritoneum which would have created the classic pain signaling appendicitis.
Dr Hawkins told the inquest she had seen Elspeth around 7pm on 3rd July last year. Although her temperature and heart rate were high, other observations were normal, she said. She was screened for sepsis, but did not trigger a concern as her temperature was below the 38.5-degree marker.
Dr Hawkins defended the decision not to put Elspeth on a drip – which had been suggested to Mrs Moore by the GP earlier that day.
She said: “We made a plan to do a fluid challenge, offering 5ml for every five minutes. It's a structured way of making an assessment of whether a child needs extra fluids.”
She told the inquest that she felt Elspeth was “most likely” suffering from gastroenteritis due to her loose stools and added: “I did consider appendicitis but in the absence of a tender abdomen I thought it was less likely.”
Turning to the decision to allow Mr and Mrs Moore to take Elspeth home as they felt she would be more comfortable, Dr Hawkins said: “With retrospect, should I have encouraged you to stay? Maybe. It's a very tricky situation.
"When you send a child home, that discussion is shared. As a clinician we are told to listen to parents.”
Dr Hawkins said she felt the couple left the unit with appropriate advice which included coming back if the situation got worse.
However, Mrs Moore said they would not have left if had they known Dr Hawkins had wanted to carry out a second set of observations after the fluid test.
She said: “We were caring parents, we knew something was wrong and we would have stayed. We would have panicked [if it was suspected appendicitis] but known we were in the right place.”
Consultant paediatrician Dr Nicola Trevelyan had been on call on the night Elspeth was taken to A&E by ambulance.
'There were some things that can be learnt'
She was then involved in investigating her death and told the court: “It was felt throughout the department that there were some things that can be learnt from Elspeth’s case. One of the outcomes is that we should be giving written advice to parents [at discharge].”
A report by the divisional head of nursing, Louisa Green, found there had been “a missed diagnosis of evolving sepsis, secondary to appendicitis”.
It said: “Given that the presentation of appendicitis in children of this age overlaps with those of gastroenteritis, there may have been confirmation bias that this was gastroenteritis, given the history of watery diarrhoea and vomiting.”
The report added there was not clear communication to Mr and Mrs Moore of what triggers there should be for returning to the hospital, nor that the gastroenteritis diagnosis should be reviewed if her symptoms worsened or changed.
Although the nursing assessment was carried out by an experienced healthcare assistant, the report said it would have been preferable for this to have been done by a registered nurse to provide “additional safety netting advice".
Coroner Grahame Short recorded a conclusion that Elspeth died due to natural causes. He added: “The death of a five-year-old girl in these circumstances is self-evidently sad. We don't expect children to die of such afflictions in this way.
“Neither the pathologist or the clinicians can say when the appendicitis started, but it is my belief it was definitely happening at that time [she fell ill].
“I find the symptoms were ambiguous and they were entirely consistent with a gastric infection. It was not unreasonable for [Dr Hawkins] to prefer that diagnosis. It was not a classic example of someone with pain in their abdomen and therefore it was not an unreasonable diagnosis.”
'There was insufficient advice'
He added: “I do find that there was insufficient advice given to Mr and Mrs Moore on how to care for her at home and more importantly, what to look out for to bring her back to hospital.”
Speaking after the inquest, Mr Moore told the A&T: “At no point was it ever mentioned to us that the diagnosis could potentially be appendicitis and if we had known this was even a possibility then we would obviously have stayed and completed the fluid challenge on-site.
“As it was, no further observations were made and we were allowed to leave, believing the diagnosis to be gastroenteritis.”