Rose Harfleet died at Royal Surrey Hospital in Guildford after visiting the emergency department the day before with her mother, as she had been experiencing vomiting
The death of a 12-year-old girl at an NHS hospital was preventable, a coroner has ruled.
Rose Harfleet passed away at Royal Surrey Hospital in Guildford after visiting the emergency department the day before with her mum, following a sudden onset of abdominal pain and vomiting earlier that morning. However, there was “failure” of the medical and nursing staff to “appreciate Rose was clinically deteriorating,” a report released on Tuesday read.
The tragedy has now led to concerns over the management of children with profound disabilities within hospital settings. Rose was diagnosed with global developmental delay (GDD) at birth, and also had a background of chronic intermittent constipation.
But the youngster, who was suffering from intestinal obstruction after she vomited green bile during her admission to the hospital, was treated for constipation the day before she died. According to the coroner’s report, Rose’s death “would have been prevented” if she had been transferred to St George’s Hospital in Tooting, south London for curative surgery.
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The Royal Surrey County Hospital NHS Foundation Trust has apologised “unreservedly” to the family for its failures. Although the plan was made to transfer Rose for further assessment and management at St George’s, this was not carried out and she died within hours on January 30, 2024 after experiencing a cardiorespiratory arrest.
An autopsy confirmed the abdominal pain, and clinical deterioration was due to a caecal volvulus causing intestinal obstruction and bowel ischaemia. The report released on Tuesday noted this and said Rose’s mother was not given the opportunity to “actively participate” in the care and management provided to her daughter, which reportedly resulted in “poor clinical decisions” that contributed to Rose’s death.
In the report, Dr Karen Henderson, assistant coroner for Surrey, said: “This gives rise to a concern that by not listening to parents or guardians as a matter of course leads to discrimination of disabled children.”
The coroner went onto say she found the ongoing concerns Rose’s mother had when she was transferred to the children’s ward “were not recognised” by the nursing and medical staff and “consequently not acted upon”. She went on to suggest this thereby contributed to the 12-year-old’s death.
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Dr Henderson added: “There appears to be a prevailing culture that in the absence of a patient being able to explain their symptoms themselves the voice of the parent or guardian is not given the significance it should be for the most vulnerable in a hospital setting.”
Additionally, the coroner’s report also found that despite the fact that Rose’s admission came during the working week, there was “no consideration or offer given” by hospital staff to provide the mother and daughter with a Learning Disability Liaison Nurse.
“This led to Rose’s mother being unsupported during this admission or for a nursing professional to be able to liaise and advocate for Rose and her mother with medical and nursing staff in the emergency department.”
And, as Surrey Live reports, he coroner’s report states that had the transfer to St George’s hospital been facilitated for Rose, so that she could have had surgery; her death could have been prevented.
Louise Stead, group chief executive of Royal Surrey and Ashford and St Peter’s Hospitals NHS Foundation Trusts told SurreyLive: “I unreservedly apologise to Rose’s family for the failures in her care and am deeply sorry for their devastating experience.
“I appreciate that no words or actions can bring Rose back or reduce the grief felt by her loved ones and can only offer the assurance that we have carried out a thorough investigation into all aspects of this tragic case and implemented several areas of learning.”
“We will now go through all of the coroner’s recommendations to further review our practices and ensure we take every possible action in response to this extremely distressing incident.”