Isabel Lily GENTRY · Prevention of Future Deaths report

On 24th May 2016 I commenced an investigation into the death of Isabel Lily GENTRY, Aged 16.

The investigation concluded at the end of the inquest on 17th March 2017.

The conclusion of the inquest was that the medical cause of death should be recorded as

1a) Group B meningococcal meningitis

Box 3 read as follows:

Isabel Gentry had meningitis, she became ill on 17th May 2016 her symptoms included: headache all day but worse in the evening; neck pain; a fever, shivering, vomiting, muscular pain, dizziness and she had fainted once, she also loose stools for 3 days. The paramedic that examined her considered that she may have sepsis as part of his differential diagnosis. Isabel was taken to hospital. The doctor did not take an accurate history or a full history and did not reach a differential diagnosis which should have included sepsis and SIRS. The observations and the bloods taken were not normal. The diagnosis of viral gastroenteritis was not accurate. The vital signs were not considered in the light of the fluid and medication she had received. The previous case of meningitis was not acted upon. There was no senior review. Isabel was discharged on the morning of 18th May. During that day she became more unwell Isabel was taken back to the Bristol Royal Infirmary that evening was treated but her condition deteriorated and she died on 20th May 2016.

The circumstances were recorded in Box 3 which are reflected above.

In summary Isabel Gentry became ill with meningitis on 17th May 2016. She attended the Bristol Royal Infirmary and was discharged on 18th May with a diagnosis of viral gastroenteritis.

As the day progressed she became more unwell and was readmitted to the Bristol Royal Infirmary on 18th May that evening. The diagnosis of meningitis was confirmed and sadly despite appropriate care and treatment her condition deteriorated and she died on 20th May 2016.

1. Evidence was provided during the inquest that if Isabel had received the meningitis B vaccination that her death would have been prevented. There is therefore an ongoing risk that future deaths will occur unless action is taken in relation to extending the vaccination program to include the teenage group which is at increased risk.