A leading children’s hospital has apologised for ‘failures’ which led to the death of a teenage leukaemia patient.
Robyn Louise Ellson, 15, suffered a toxic reaction to a clash of medication, an inquest heard.
She was in remission from the leukaemia, but her kidneys were failing because of the disease.
Doctors at Alder Hey Children’s Hospital, Liverpool, did not realise that a combination of low-dose chemotherapy and kidney dialysis would have fatal consequences.
A leading children’s hospital has apologised after blood cancer patient Robyn Louise Ellson, 15, suffered a toxic reaction to a clash of medication and died
Robyn had been discharged but was re-admitted on January 11 2013 with bleeding gums, skin blisters, headaches and nose bleeds.
Her condition deteriorated, blood clots formed in her airway, she suffered two cardiac arrests and she died in the early hours of January 19.
At an inquest at Liverpool Coroner’s Court last week, area coroner Anita Bhardwaj concluded ‘Robyn’s care and treatment was poor’.
She criticised the hospital for a ‘series of issues’ which had contributed to Robyn’s death, including ‘a failure to take account of (her) chronic renal condition’ and ‘a failure to recognise a deterioration’ in her condition.
Robyn, of, Flintshire, north Wales, had been diagnosed with cancer in August 2012 and battled through gruelling rounds of chemotherapy after being transferred to Alder Hey from the Countess of Chester Hospital.
Dr Mark Caswell, a consultant haematologist at Alder Hey, described Robyn’s death as ‘a tragedy’.
He said: ‘This was a huge shock to us all and a huge wake-up call. We are all devastated and we should have anticipated these problems.
‘It was an unexpected reaction. So few children suffer from renal failure that these were unexpected issues that we did not recognise. We are reliant on guidelines but this was something that we just don’t experience.’
Robyn was in remission from leukaemia, but her kidneys were failing because of the disease. Her treatment at Alder Hey Children’s Hospital, Liverpool, was described as ‘poor’
The cause of death was given as asphyxiation as a result of a respiratory tract haemorrhage, methotrexate (oral chemotherapy drug) toxicity, renal failure and acute promyelocytic leukaemia (APL).
The leukaemia had caused chronic renal failure and as a result Robyn was put on ‘maintenance therapy’ which saw her receive low doses of methotrexate while on dialysis.
A meeting held in December 2012 was described as ‘a missed opportunity’ to discuss her condition and the coroner urged nurses to keep better notes of treatment and meetings.
‘Robyn’s care and treatment was poor,’ added Ms Bhardwaj who recorded a narrative verdict before offering her sympathies to the teenager’s family and friends.
A statement from Robyn’s distraught parents, Garry and Debbie, said: ‘Robyn was the most caring young girl you could ever wish to meet and made friends easily because everyone who met her loved her.
‘She loved school, especially music and drama, and being in Girl Guides, Explorers and the Duke of Edinburgh scheme.
Robyn’s heartbroken parents Garry and Debbie said: ‘Nothing will bring Robyn back, but what’s important to us now is that there is accountability and change to stop this happening again’
‘She wanted to work as a primary school teacher and had her whole life planned out.
‘As a family we still struggle with the huge hole her loss has left in our lives – the impact runs deeper than anyone can imagine.’
The statement continued: ‘Basic training tells you to look at someone’s health records to check whether medication is appropriate and to think they didn’t do that is terrifying.
‘Nothing will bring Robyn back, but what’s important to us now is that there is accountability and change to stop this happening again.’
Catherine Wardell, Alder Hey’s associate chief nurse for medicine, told the inquest systems had been overhauled.
A statement from Alder Hey Children’s NHS Foundation Trust said the trust ‘accepted failures were made’ during Robyn’s treatment.