Mone Jahni Karl White · Prevention of Future Deaths report

On the 12 July 2012 I opened an inquest touching the death of Mone Jahni Karl White, aged 3 years old. The investigation concluded at the end of the inquest on the 17th January 2014. The conclusion of the inquest was “Narrative verdict”, the medical case of death was ;1a Acute heart failure, 1b Asthma/ chest infection, and under paragraph 2 Dilated cardiomyopathy.

Mone suffered with dilated cardiomyopathy, probably caused by a viral infection. Mone was under the care of the Royal Brompton hospital and had repeated episodes of illness requiring hospital treatment precipitated by infections.

The Royal Brompton Hospital had in 2010 produces a document giving guidance to those who may come into contact with Mone. A copy was sent to Northwick Park Hospital and the London Ambulance Service and Mone’s parents had a copy.

Mone was admitted on the 5th July 2012 having been brought into Northwick Park Hospital by ambulance with an episode of illness.
The doctors who treated Mone had not seen this document despite there being a copy in the medical notes.

On the 7th July 2012 Mone’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 Mone.

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

If Mone had been referred and been accepted by the Royal Brompton Hospital on the 5th or the 6th July 2012 it is likely that he would not have died when he did.

(1) 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.