A father has won a High Court battle for a fresh inquest into the death of his young son, who died after an alleged refusal by a senior physician to see him as his condition worsened.
A judge quashed a Worcestershire deputy coroner’s verdict that 14-month-old Thomas Duffy died in hospital of natural causes.
The deputy coroner reached her June 2012 decision, despite concerns raised over Thomas’s treatment at the Alexandra Hospital, Redditch. It is part of Worcestershire Acute Hospitals Trust.
Mr Justice Kenneth Parker, sitting at London’s High Court, ruled that the deputy coroner “reached a conclusion which, on the balance of relevant factors, was not reasonably open and was at real risk of causing substantial injustice”.
The judge directed that a new inquest should take place “as expeditiously as possible”.
He said there was “very great force” in submissions that the public interest required “a broader inquiry” than that adopted by the deputy coroner.
Mr Duffy and his wife took Thomas to the accident and emergency department at Alexandra Hospital in the early hours of March 19, 2011 after he had been unwell with what appeared to be bronchial problems.
Thomas had a history of recurrent chest infections, and his condition had deteriorated since the previous Christmas. He had become much worse since 11am the previous day.
Unsuccessful attempts were made to treat and resuscitate him in hospital and he was pronounced dead at 9am.
The judge said the evidence before the coroner was that locum paediatric registrar Dr Natarajan had at one stage - some time around 5.47am - become so concerned about Thomas’s condition that she contacted the on-call paediatric consultant, Dr El-Azzabi, and asked him to attend the hospital.
The judge said: “Dr El-Azzabi refused. She (Dr Natarajan) stated that she was hesitant to insist that he come to examine Thomas.”
Dr El-Azzabi eventually attended after being told that Thomas had suffered a cardio-respiratory arrest at 8.10am.
The inquest was originally due to last six days with a considerable number of witnesses expected to give evidence, including Dr El-Azzabi and Dr Natarajan.
But the deputy coroner reached her verdict after hearing only from a pathologist and Dr Elliott Shinebourne, an expert appointed by the coroner’s court, who had been a consultant paediatric cardiologist at the Royal Brompton Hospital in London from 1971 to December 2007.
The judge said the position of Dr Shinebourne “gave rise to real concern” as he had not been concerned with intensive care of children for 15 years.
Dr Shinebourne gave expert evidence that failures in Thomas’s treatment “might” have caused his death, although, on a balance of probability, the child would have died in any event.
However Dr Shinebourne was not able to deal fully and adequately with questions raised, including whether inappropriate management of the level of fluids given to Thomas might have contributed to his death, said the judge.
He ruled the coroner had wrongly refused the Duffy family’s request for further evidence to be obtained from an expert with current experience in the intensive care of children.
The judge said Mr Duffy had since obtained an expert medical report from Dr B Tsai-Goodman, a consultant paediatric cardiologist at Bristol Congenital Heart Centre who did have “current - and impressive - relevant experience”.
Dr Tsai-Goodman’s conclusion was that “it was more likely than not that, with appropriate supportive measures and cautious fluid management, Thomas would have survived that evening”.
The judge said there was also “very great force” in submissions that it was incumbent on the deputy coroner to make further inquiries and to hear from Dr El-Azzabi and Dr Natarajan , as originally contemplated.
James Dixon, appearing for Mr Duffy, had also contended there was evidence before the deputy coroner of possible systemic failure at the hospital - “namely the refusal of the on-duty consultant to attend the hospital when the registrar, who was treating Thomas and extremely anxious about his deteriorating condition, had requested the presence and direct involvement of the senior physician.”