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Investigation and inquest
On 12th December 2013 I commenced an investigation into the death of Lucy Maria GOULDING, 16 years of age. The investigation concluded at the end of the inquest on 12th December 2013. The medical cause of death given was:
1a. Brain stem herniation
1b. Hydrocephalus
1c. Pilocytic astrocytoma
2.
My narrative conclusion was: Lucy Goulding died from brain stem death arising from raised intracranial pressure due to a benign cystic astrocytoma in circumstances where there was a delay in investigation and diagnosis and where deterioration went unrecognised, all of which could have affected the outcome.
Circumstances of the death
Lucy Goulding presented with a relatively short history of headaches to her GP who diagnosed tension headaches or migraine. Her headaches worsened substantially and her mother dialled 999 and Lucy was admitted into hospital at around 1400 on 26th June 2013. No formal assessment, investigation or management was undertaken for her headache during her time in hospital. A referral to the community mental health team was made to be made the following day when admitting doctors planned discharge. Lucy was transferred to the paediatric ward where neurological observations were not carried out. Lucy's headache persisted and worsened despite being treated with painkillers. She collapsed and had a cardiorespiratory arrest at or around 0300, 27th June 2013. She was intubated and ventilated and an emergency CT scan found a brain tumour, which was a benign cystic astrocytoma. Lucy was transferred to the neurosurgical unit at Southampton General Hospital for emergency treatment to relieve the pressure on her brain and to remove the benign tumour but she did not recover from her collapse at Worthing hospital and Lucy was confirmed dead at 21.12 on 27th June 2013 in the neurological ITU at Southampton General Hospital.
Coroner’s concerns
1. Lack of consultant supervision of on-call paediatric trainees or sub-consultant paediatric doctors admitting paediatric patients as an emergency into Worthing Hospital
2. Lack of independent consultant assessment of paediatric admissions into Worthing Hospital in and outside normal working hours
3. Lack of national guidelines for assessment and investigation of headaches in children
Information checked against the published report and official responses