An NHS hospital has apologised after the ‘completely avoidable’ death of a ‘full of life’ schoolgirl.
The heartbroken family of Isla Mae Hudson have paid tribute to the teen after she died at the Royal Stoke University Hospital following a catalogue of blunders.
Isla, from Whiston, had been admitted after suffering with severe stomach pains. But an inquest heard she was given a high dose of morphine when she suffered from myotonic dystrophy instead of gradually increasing the dose.
In addition to this, a CT scan was delayed by 12 hours due to protocol stating that a pregnancy test needed to be carried out. By the time the scan was done, the surgeon who would have then carried out an operation had gone home.
Isla passed away on September 13 2023 having never had the operation. Further failings included delays in giving fluids, Isla’s weight not being taken at any point and infrequent clinical observations, reports Stoke Live.
Now a coroner has deemed Isla’s care to have been ‘inadequate’ with the issues ‘substantially causing her death’. A 38-point plan has since been drawn up by University Hospitals of North Midlands NHS Trust – which runs Royal Stoke – to prevent similar mistakes leading to future child deaths.
Speaking at the inquest, Isla’s father Richard Hudson said: “Isla’s death was untimely. She loved life, she loved every minute of school – she was happy. It was such a shock to lose her, as we said in our original statement, it’s unbelievable it’s happened. It seems like yesterday, it’s been nearly 18 months and it doesn’t get any easier.
“Our son was only six-years-old when it happened, and every couple of weeks he’ll cry. Isla loved him so much and they’d play together on the tablet and they’d lie on the bed together even though they’d be doing separate things. They were like two peas in a pod despite being very different children.
“She was so full of life and I believe she had decades of a happy life [ahead of her], and she’s been robbed. Things will never be the same for our family.”
Assistant Coroner Duncan Ritchie delivered a narrative verdict saying: “Isla Mae Hudson was a normal teenage girl. She did have myotonic dystrophy – muscle weakness and wasting – which can lead to problems with the bowel.
“On September 1 2023, Isla’s pain was unbearable, so her parents took her to the Royal Stoke University Hospital. On the evening of September 11 2023 Isla was unwell again, and she was admitted to Ward 217 – and she was given fluids intravenously and morphine.
“An initial radiologist report suggested bowel obstruction could be the cause of Isla’s pain. The paediatrician who led the investigation offered the opinion that Isla’s cause of death was a combination of chronic acidosis and myotonic dystrophy that gave her respiratory problems and she shouldn’t have been given that much morphine, especially because she had not had it before.
“Dr Caroline Groves gave her opinion that Isla was more susceptible to the side affects of morphine including respiratory oppression, and as the longer of Isla’s bowel was twisted, there was a greater risk of a lack of blood supply to the bowel, which can cause acidosis. Firstly, when Isla was admitted to hospital she wasn’t weighed – this is important because the dosage of medications administered is dependant on weight.”
He continued: “There were mistakes with the morphine administered, because Isla suffered from myotonic dystrophy it meant that it can cause respiratory problems. Furthermore, the dose of morphine – 5mg – was the highest recommended dose for Isla’s weight and age. What should’ve been done is to administer the lowest dosage, and then slowly increase it if needed.
“People with muscle problems are more susceptible to this side effect of morphine because their muscles are weakened. Isla’s clinical observations weren’t carried out as frequently as they should’ve been – they should’ve been hourly, not four-hourly like in Isla’s case. Had observations been carried out then respiratory oppression may have been detected, but it wasn’t.
“Isla’s fluid levels weren’t maintained, there were too little fluids given, there were gaps in the fluids given, and the fluids didn’t contain glucose as they should’ve done, resulting in Isla receiving insufficient fluids for over 24 hours. Blood tests were carried out by the paediatrician on September 12 and the results suggested Isla was acidotic – she was seriously unwell – and they corrected the fluids to be administered. They thought the cause of acidosis was because Isla wasn’t hydrated.
“Isla’s blood results were not shared with the surgical team which might have shown a change in her condition, and therefore might have changed her treatment. The surgical registrar refused to give Isla a CT scan because a pregnancy test needs to be done first, which should’ve been overridden.
“On September 12 [after a 12-hour wait] the senior doctors were not available to look at Isla’s CT scan, which would’ve removed the need for morphine and it would have shown the effect morphine was having on her breathing. The CT scan report was formatted in a way to miss significant challenges in the report – there was a large blank gap at the edge, meaning at least one doctor had missed the report completely when checking Isla’s electronic record.
“Isla’s requirement needed immediate surgical intervention, but no observations had taken place until she went into cardiac arrest.”
Ann-Marie Riley, UHNM Chief Nurse, said: “We would like to offer our sincere condolences to the family of Isla and are truly sorry that her care fell below the standard she was entitled to receive.
“Following an extensive review into Isla’s care, we have implemented changes to our practices and procedures and will be closely monitoring improvement actions to ensure learning from her case is embedded.”