A CHILD who bled to death at Sheffield Children’s Hospital could have been saved if he had been treated at ‘any other children’s hospital in the UK’, an inquest heard.
The verdict of independent expert Dr David Crabbe came at the conclusion of a hearing into the death of two-year-old Tharun Umashankar.
Coroner Christopher Dorries ordered a report of the findings to be issued under Rule 43 of his court, urging action to prevent further deaths.
Tharun was admitted to Barnsley Hospital and transferred to Sheffield Children’s Hospital on July 10, 2010, suffering from a severe bleed in his sotmach lining and died in the early hours of the following morning.
An eight-day inquest held at Sheffield’s Medico Legal Centre in March heard the youngster had been admitted to hospital vomiting blood twice in the fortnight leading up to his death, thought to be caused by an intolerance to milk.
When he was admitted to Sheffield Children’s Hospital a third time, consultant paediatric gastro-enterologist Dr David Campbell ordered an endoscopy to be carried out the next day.
Tharun’s mother Sentamil, aged 38, broke down as Mr Dorries said Tharun’s life might have been saved if the procedure was carried out straight away.
Mr Dorries said: “The independent expert Dr Crabbe is critical that once Tharun’s admission was known there wasn’t a clear plan formed between seniors of gastroenterology and surgery, with a fall-back plan if there was a re-bleed.
“He feels that it was an error of judgement not to have proceeded to endoscopy that afternoon by the surgeons with, he says, the likely result of an overall bleed being recognised.
“Dr Crabbe is confident Tharun would have survived if this would have been undertaken, indeed to quote ‘I’d go as far as to say that had he been admitted to any other children’s hospital in the country, he’d have gone in under the surgeons, had endoscopy that afternoon and survived’.”
At the previous hearing Dr Campbell said he had instructed staff to contact him if Tharun had another bleed before he went off duty that weekend.
But when his condition deteriorated, colleagues did not make the call.
Both Mrs Umashankar and her husband Sivananthan, aged 42, a petrol station cashier, who ran a grocery store in Barnsley at the time, heard it was a factor which led their son’s death.
Recording a narrative verdict, Mr Dorries said: “On the basis of expert opinion there was a failure to plan and a failure to communicate about a child known to be at serious risk. Endoscopy and surgery on the previous day would likely have saved Tharun’s life but such was a matter of judgement rather than specific failure.”
A spokeswoman for Sheffield Children’s Hospital said the referral pathway has since been changed.