Kinga Cieciorska · Prevention of Future Deaths report

On 11 March 2016, I commenced an investigation into the death of the child, Kinga Cieciorska. The investigation concluded at the end of the inquest on 10 June 2016. The conclusion of the inquest was the deceased died by way of natural causes contributed to by neglect. The cause of death was:

1a) Peritonitis
1b) Perforated gastric ulcer
2) Cerebral Palsy

1. Kinga was a 16 year old girl born with a number of complex medical needs including cerebral palsy, scoliosis, and dislocated right hip and was visually impaired. She was on various medications including Diclofenac and one of the recognised side effects is stomach ulcers.

2. Her parents became concerned and she appeared to be in pain and discomfort with her abdomen becoming distended. The family took her to her GP and he advised that she should be admitted to Hospital for checks. She was subsequently taken to Walsall Manor Hospital. He also sent notes of his examination and background medical history for the Hospital to use to assist in any diagnosis. It transpired during the inquest that these notes provided by the GP were not seen by the Junior Doctor or Triage Nurse who initially examined her when she arrived.

3. The Junior Doctor after examination recorded that her abdomen was soft and tender. The family asked for an ultrasound scan but this wasn’t considered necessary and the working diagnosis was constipation. The Junior Doctor discussed the case with his supervising Consultant, and he advised that an ECG be performed and that further advice should be sought from the on call Paediatrician. The ECG revealed sinus tachycardia.

4. The Junior Doctor didn’t record the name of the Paediatrician he spoke to but says he was advised there was no problem or concerns in relation to the tachycardia and she could be discharged with Movicol medication for constipation.

5. The Paediatrician identified by the rota provided a statement denying he had given any advice in relation to the patient and couldn’t recollect any conversation with the Junior Doctor.

6. Kinga was discharged home. Her condition deteriorated rapidly overnight and she became unresponsive. She was urgently taken back to Hospital in her father’s car on the morning of the 11 March. Sadly, despite resuscitation attempts she couldn’t be revived and had passed away.

1. Evidence emerged during the inquest that the abnormal ECG trace and tachycardia needed further investigation and she should have been subject to further tests and admitted for further observation to establish the cause of the tachycardia. This was effectively a missed opportunity to render basic medical care. On the balance of probability it is more likely than not, she may have survived or life may have been extended if tests had been done to confirm the diagnosis of peritonitis and appropriate treatment commenced.

2. During the inquest it emerged there was evidence of systemic failings in recording of and transmission of information. The Junior Doctor failed to record the name of the Specialist Paediatric Registrar giving advice. More worryingly the Paediatric Registrar at inquest could not recollect giving any advice in relation to the patient. It also emerged during the inquest that medical notes provided by the GP were given to reception staff by the parents on admission. Unfortunately these documents were not forwarded or seen by the Junior Doctor on examination of the patient.

3. It also emerged during the inquest that details of her medication including the significance of the drug, Diclofenac was not considered. One of the contra-indications of this drug for long term users is gastric ulcers. Many people take NSAIDs without having any side effects, but there's always a risk the medication could cause problems, such as stomach ulcers, particularly if taken for a long time or at high doses.