Miss Akua Anokye-Boateng · Prevention of Future Deaths report

On 23rd January 2013, I opened an inquest into the death of:
Miss Akua Anokye-Boateng, aged 7 years, died 16th January 2013,
Case Ref: 00154-13.

It was concluded on 26th March 2014.
The court found that the medical cause of death was:
1a Acute Peritonitis and Shock
1b Perforated Duodenum
1c Non steroidal anti-inflammatory (NSAID) ingestion and Helicobacter associated chronic ulceration of duodenum in sickle cell disease

The following narrative was recorded:
Akua had well managed and well controlled sickle cell disease. She suffered a 3 day illness, consulting her GP but collapsing suddenly, unresponsive to prompt resuscitation and dying at 19.16 at KCH on 16.01.13. She had ingested a non steroidal anti-inflammatory drug in May 2012 and suffered a GI upset in August. Her death was unrelated to sickle disease and was caused by unexpected duodenal perforation, although chronic and multi-factorial.

Expert evidence was heard from an experienced academic pathologist that one dose of NSAID was sufficient to damage the GI mucosa in children, which, coupled with a presumed Helicobacter infection, led in this case to the perforation. The consultant paediatrician with responsibility for haemoglobinopathies was unaware of the risk of a single dose in the past and gave evidence that Ibuprofen was an important drug in the management of sickle cell patients, having less side effects than opiates. He reported that it is not current practice to routinely give gastro-intestinal protection when NSAIDs are used briefly in children with sickle disease. Thus it is unclear what is best practice or whether the scientific evidence suggests that guidance is needed for clinicians about further precautions or prevention such as Proton pump inhibitors being routinely used alongside NSAIDs in children, to minimize the risk of similar deaths.