An investigation was launched after a 12-year-old girl collapsed at home and died unexpectedly of Crohn’s disease after ‘several’ trips to see her GP.
The unnamed girl made the visits to her family doctor with stomach pain but after a few weeks her condition worsened and she began vomiting ‘Coca-Cola-like’ dark liquid.
She died after she stopped breathing while at home.
A probe into the practice’s handling of her treatment ruled the unnamed girl would still have died of the chronic condition, which inflames the intestines and can cause internal bleeding, with earlier treatment.
But the practice, which has also not been identified, was told to make more routine checks on children who complain of stomach problems.
The case emerged in a report made public by the Nottinghamshire Safeguarding Children Board. It revealed 50 children in the county died over the last year.
The report also said a “learning and improvement bulletin” – which focuses on GP responses to weight loss and abdominal pain in children – was produced following the review of the death of the girl, referred to only as ‘Gabby’.
Gabby was healthy with no significant previous health issues other than asthma, the bulletin said.
It added: “Gabby presented several times over a seven-week period to her General Practitioners (GPs) with epigastric discomfort, some weight loss and occasional vomiting.
“Her mother had also been in touch with school nurses as she was concerned regarding her weight loss.
“The school nursing team had been involved in a support plan which included the plotting of Gabby’s weight with a referral to the dietician due to a noticeable drop in weight to the 0.4th centile.”
On the day of her death, Gabby was reportedly ‘fine’ at school and had completed a PE lesson with no complaints. She later played at home but complained of stomach ache in the evening.
She went to bed but vomited a couple of hours later. Her mother described it as “very black, like Coca-Cola”.
She went on to vomit three to four times in the night, and at about 6.20am, she needed help to the toilet, and then went back to bed.
She was later heard gasping and found to be pale and struggling to breathe. She later stopped breathing.
Paramedics were called and during resuscitation, Gabby continued to vomit black liquid. She died shortly after.
A post-mortem into her death revealed she died of intestinal perforation with peritonitis and sepsis and Crohn’s disease. The report added a coroner decided not to hold an inquest into the death.
The report added when she went to her GPs, her urine and weight were not checked. This was identified at an initial child death rapid response case discussion and was the subject of an internal “GP serious incident investigation”.
The investigation found no intervention would have prevented the death, but some “learning points” were identified – such as ensuring a urinalysis is performed for a child with abdominal pain.
The GP practice has introduced changes to their procedures for when a child arrives with abdominal pain, like stool sampling, but this would not have identified results that could have prevented the child’s death as Gabby “lacked clinical signs which would suggest she had Crohn’s disease”.
According to the report, the “learning points” have already been implemented at the practice where the girl was registered.