Nine-year-old boy dies of chronic asthma after doctors missed diagnosis

20170327130000, Jenny Maganran Goh
Nine-year-old chess champion collapsed and died of chronic asthma after 11 missed diagnoses. Photo credit: PA/Telegraph
A nine-year-old boy from London had multiple consultations with NHS doctors and private practitioners in seven months, before he succumbed to chronic asthma five days after his discharge from hospital in the UK.

Westminster coroner Dr Shirley Radcliffe said, “There was 11 opportunities within seven months to appropriately test, diagnose and treat him.”

"Alarm bells should have begun to ring" when Michael was admitted to hospital twice within 24 hours, said the coroner.

Medical history obtained was “totally inadequate”

His mother, Avelet Uriely strongly felt that her son was denied basic care. When she saw his condition deteriorating, she had discussed the likelihood of death with a doctor as early as February that year but was told that Michael was “not in this category”.

Even her requests to refer Michael to an asthma clinic as well as the Great Ormond Street Hospital in London were denied as she claimed the doctor felt that Michael “didn’t require it”.

Soon after, Michael had serious asthma attacks and was admitted to the Royal Free Hospital on 18 August. But again, a proper diagnosis was lacking and the boy was discharged with the assumption that he would grow out of his asthma. Michael’s mother said they were told "something like we were wasting their time”.

However, the next morning Michael was re-admitted for violent bouts of vomiting and a bloated chest, to which doctors said he was just being “hysterical”.

According to Dr Radcliffe, "totally inadequate" medical history was obtained on that occasion and no connection was made with his previous admission.

Worried over her son’s inappropriate discharge, Uriely booked an appointment with Dr Aisha Laskor, who expressed shock over the doctors’ oversight.

Doctors deny allegations

According to the inquest, there were disputes between Dr Laskor and the boy’s mother on what transpired during the consultation.

Dr Laskor said her “gut instinct” was to refer Michael back to the hospital, but Michael’s mother had told her he was getting better since his discharge. The doctor added that she told them to stay in the waiting room for 20 to 30 minutes to observe his condition.

Dr Laskor said that his mother “did not appear desperate.” Adam Korn, representing the Uriely family, said Dr Laskor was saying that to “justify” her decision to send him home. However, Dr Laskor said she was still questioning her decision that evening.

The inquest also queried Dr Michael Greenberg, from Wellington Outpatients Centre in Golders Green, who was said to have denied Uriely’s request for referral to Great Ormond Street Hospital. The doctor said he could not recall the conversation and added, “I would have happily made those referrals.”

Paediatrician Dr Neil Thompson, who had seen Michael at the Royal Free Hospital on 18 August, denied using the word “hysterical” on Michael.

Patient’s asthma was “poorly controlled” in his last year

Meanwhile, Mark Levy, a veteran GP of 40 years and author of more than 140 papers on asthma, said that the boy’s asthma was “poorly controlled” in the last year of his life.

“The respiratory rate of 36 that Michael had during the August 21 appointment is considered to be 'life threatening'.”

Michael was diagnosed with asthma when he was two and a half years old. Described by his mother as ‘highly gifted’, the boy learned to play chess six months after the diagnosis. He began clinching championships in national and regional chess competitions, and won the title of National Chess Champion.

Michael had all the making of a chess prodigy but everything ended on 25 August. His untimely death could have been spared if doctors had been more diligent in their diagnosis. MIMS

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Sources:
http://www.dailymail.co.uk/news/article-4316644/Boy-9-died-doctors-missed-11-CHANCES-save-him.html
https://www.theguardian.com/uk-news/2017/mar/15/doctors-missed-11-chances-to-treat-boy-nine-before-he-died-of-asthma-coroner-hears
http://www.telegraph.co.uk/news/2017/03/15/doctors-missed-11-chances-treat-chess-champion-months-died-chronic/
http://www.bbc.com/news/uk-england-london-39297827