A toddler may have died from meningitis because an inexperienced doctor failed to diagnose his condition on time, a coroner in Northern Ireland ruled today.
Rhys Brady was found to have a purpuric rash - a major symptom - when he was examined in Daisy Hill Hospital, Co Down at 1am on May 16th last year.
But the 17-month-old was not diagnosed with meningococcal septicaemia until 6.30am - more than five hours later.
Coroner John Leckey identified six factors which may have prevented Rhys's death in the early hours of May 17 but stressed there were no guarantees he would have survived.
Mr Leckey also confirmed he will be sending the inquest papers to the Health Minister and the Chief Medical Officer for Northern Ireland to highlight concerns raised about the absence of 24-hour paediatric resident cover at Daisy Hill and two other hospitals in Northern Ireland.
Belfast Coroner's Court heard the following factors, in order of importance, led to Rhys, of Mayobridge, Co Down, dying rather than surviving:
- The failure to diagnose correctly and promptly the purpuric lesion at 1am.
- The failure to commence antibiotic therapy at 1am.
- The failure to seek the advice of the on-call consultant paediatrician, Dr James Hughes, at 1am or thereafter in the period before 6.30am.
- Poor doctor/nurse communication and dialogue.
- The lack of paediatric experience of Dr Sureshchandra Madaiah (the overnight doctor).
- The absence at Daisy Hill of 24-hour resident cover by a doctor with significant paediatric experience.
Solicitor Ciaran Rafferty said the Brady family hope lessons will be learned from the case. Mr Brady said: "The coroner's findings reaffirm the family belief that the delay in the diagnosis of the illness and subsequent delay in treatment were critical factors in the untimely death of Rhys.
"The Brady family hope that such a tragedy will be avoided in the future as a direct result of a review of the procedures and practices to be implemented in similar cases."