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Investigation and inquest
On 02/11/2018 an investigation into the death of Alice Marie Sloman was commenced. The investigation concluded at the end of the inquest on 16th December 2019. The conclusion of the inquest was a narrative conclusion as follows:
Alice was born with a mitochondrial disorder resulting in her developing cardiomyopathy, skeletal myopathy, short stature and Autistic Spectrum Disorder. Her medical management was lacking in that investigations to diagnose her underlying condition were not undertaken. As a result her cardiomyopathy was not diagnosed and she died from complications of a routine general anaesthetic.
Circumstances of the death
Three days before her death Alice underwent a routine general anaesthetic for an MRI scan. The medical staff were unaware that she had a cardiomyopathy. The anaesthetic precipitated a cardiac decompensation from which she never recovered.
Coroner’s concerns
The evidence demonstrated that Alice was under the care of a consultant community paediatrician, a consultant general paediatrician with an interest in endocrinology and a consultant paediatric endocrinologist presenting with a number of conditions (Growth hormone deficiency, Autistic Spectrum disorder, developmental delay, visual impairment, mobility impairment, poor coordination/dyspraxia and hypermobility) over a 4 year period but was not referred for investigation of an underlying disorder, specifically a clinical geneticist’s opinion, despite her parents requesting this on at least 2 separate occasions which are documented and despite such facility being readily available in Exeter. The evidence demonstrated that as a result her underlying condition, and specifically a serious cardiomyopathy, went undiagnosed resulting in her dying unexpectedly and prematurely as a result of a routine general anaesthetic.
Information checked against the published report and official responses