The death of a 15-year-old girl who entered cardiac arrest and who died just hours after being informed that she had had an ear infection was due to negligence. , ruled a coroner.
Rosie Umney, a student at Herne Bay High School, a Type 1 diabetic, was taken to William Street Surgery on the evening of Monday, July 2, where she was examined by Dr. Sadaf Mangi.
She had some of the symptoms of ketoacidosis – vomiting, hyperventilation and difficulty walking.
Previously, the doctor had stated that she initially thought that Rosie could have contracted the disease after learning that she was type 1 diabetic.
But she thought the opposite after Georgina Umney had said that her daughter's blood glucose results were normal that day.
Instead, a schoolgirl in the ear was diagnosed and antibiotics were prescribed to the schoolgirl.
An ambulance was called at Rosie's on South Road that night, after her mother could not wake her up.
She was transported to QEQM Hospital in Margate before 2:10 am, where she died.
An autopsy later revealed that his cause of death was diabetic ketoacidosis.
During an investigation into his death at the Canterbury Coroner's Court, the Assistant Coroner, James Dillon, testified that Dr. Mangi had not followed the guidelines issued by the National Institute of Health and Care (Nice ).
They claim that a patient should be sent to the hospital if he has symptoms such as shortness of breath, illness and high temperatures.
The GP had previously admitted that she was not aware of the recommendations published by Nice.
Mr. Dillon said, "Rosie Umney was admitted to the hospital early in the morning of July 3, in an advanced state of diabetic ketacidosis.
"His condition was not recoverable. The GP did not send her to the hospital, but Nice's instructions would have sent her to send Rosie there.
"The doctor did not check his blood sugar level."
Mr. Dillon added that Dr. Mangi had been contrite, enrolled in refresher courses and apologized to Umney.
When paramedic Richard Steinbeck arrived at Rosie shortly before 1:10 am, his parents told him that previous tests had revealed a normal reading of 7.9 millimoles per liter.
He took two blood samples from Rosie in his earlobe and finger.
His blood sugar was so high that his machine – and another that he had borrowed from a colleague – was unable to read.
The paramedic then used Rosie's meter himself, which again returned safe values of 7.8 and 8.6 millimoles per liter.
Two months before his death, lots of test strips similar to those Rosie used were recalled by their manufacturer, Roche Diabetes Care, because they thought they could provide inaccurate results.
However, no quality control tests were performed on Rosie's tapes as their expiry date was exceeded.
"It is said that the test strips were recalled, although there is no evidence that Rosie was touched …" Deputy Coroner James Dillon
In addition, none of the equipment was sent to Roche to enable it to conduct its own checks.
"The test strips are said to have been recalled, although there is no evidence that Rosie has been touched," Dillon added.
"They could not be tested because they had passed their expiration date. Two SECAmb (Ambulance Service) counters were used independently and showed that Rosie's blood glucose was extremely high. "
At the hearing, Mr. Dillon noted that there was also evidence that Rosie's machine had not been used for "a few days".
"Dr. Mangi's involvement can not be seen in isolation," he said.
"There is evidence [Rosie] was not compliant with his diabetes surveillance and treatment regime, including blood tests.
"These have therefore led me to a conclusion of negligence."
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