GP Practice Investigated After Child’s Death

A GP practice in Nottinghamshire was investigated after the death of a child who had Crohn’s disease and was throwing up “Coke-like sick”, a report has revealed.

The annual report of the Nottinghamshire Safeguarding Children Board stated 50 children in the county died over the last year. Following the completion of other “processes” – such as inquests and criminal proceedings – the Child Death Overview Panel (CDOP) conducted 37 reviews for that same period.
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 a death involving an unnamed 12-year-old child, called “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 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.”

The report does not name the school “Gabby” went to, or the GP practice she attended.

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On the day of her death, “Gabby” was reportedly “fine” at school and had completed physical education 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”.
“Gabby” 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. This led to “Gabby” having a respiratory arrest.

Paramedics were called and during resuscitation, “Gabby” continued to vomit black liquid. She died shortly after.

A post-mortem into her death revealed “Gabby” 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 said when “Gabby” went to 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 of “Gabby”, 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 “Gabby” was registered.

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