“Evidence emerged during the inquest that the abnormal ECG trace and tachycardia needed…”
Dated 13 Jun 2016, from the coroner for Black Country. Sent to 1 organisation or person.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
Deadline passedReplies were due by 8 Aug 2016. A reply may have been sent and not yet published.
Organisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk.
- Report dated13 Jun 2016
- Deadline8 Aug 2016
- Published on judiciary.uk13 Jun 2016
- Today22 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Walsall Healthcare NHS Trust | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 8 Aug 2016. A reply may have been sent and not yet published. |
The coroner’s concerns
– 1. Evidence emerged during the inquest that the abnormal ECG trace and tachycardia needed further investigation and she should have been subject to further tests and admitted for further observation to establish the cause of the tachycardia. This was effectively a missed opportunity to render basic medical care. On the balance of probability it is more likely than not, she may have survived or life may have been extended if tests had been done to confirm the diagnosis of peritonitis and appropriate treatment commenced. 2. During the inquest it emerged there was evidence of systemic failings in recording of and transmission of information. The Junior Doctor failed to record the name of the Specialist Paediatric Registrar giving advice. More worryingly the Paediatric Registrar at inquest could not recollect giving any advice in relation to the patient. It also emerged during the inquest that medical notes provided by the GP were given to reception staff by the parents on admission. Unfortunately these documents were not forwarded or seen by the Junior Doctor on examination of the patient. 3. It also emerged during the inquest that details of her medication including the significance of the drug, Diclofenac was not considered. One of the contraindications of this drug for long term users is gastric ulcers. Many people take NSAIDs without having any side effects, but there's always a risk the medication could cause problems, such as stomach ulcers, particularly if taken for a long time or at high doses.
An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.
- Source
- judiciary.uk, Prevention of Future Deaths reports, 2016-0222
- Added to Minute Book
- 8 Oct 2026
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- We show short extracts and link to the original. We don’t host the full report.
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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0
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