A teenager who was "let down" should have been given the right specialist treatment for her survival, an inquest heard.
Katie Wilkins was 14 when an "unusual" abscess was found after she complained of unbearable vaginal pains in June 2020. However, after weeks of back and fourth to the hospital, she was not diagnosed until late July when it was found she had a rare form of leukaemia.
After a short battle with the illness, Katie died at Alder Hey hospital on July 31, 2020. The inquest into her death began earlier this week as the family say she was drastically 'let down' by medical professionals.
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On Wednesday, at the inquest held at the Gerard Majella Courthouse, evidence was heard from independent expert witness Dr Cathy Farrelly. She said that when someone presents in an usual way, as Katie had, it "raises my suspicions as a doctor that something else is going on."
She added she would "like to think" if a patient presented with unusual symptoms that it would "prompt a full review by a senior clinician at that time."
After being given two courses of antibiotics that did not ease symptoms, Katie was given a bed at Warrington's paediatric ward on July 14 with the possibility of surgery the next day. But instead, she was taken for an MRI before being discharged and no blood tests were taken.
From July 17, Katie's symptoms "worsened" and took a turn for the worse on July 26 when she collapsed at home. She was again taken to Warrington A&E before given a bed and blood tests were requested.
Speaking on Wednesday, when asked if bloods had been done earlier, would the outcome have been different, Dr Farrelly replied "it's very hard to say", but at that point, it was "likely her full blood count wouldn't have been normal."
She added that with any type of leukaemia the sooner it's diagnosed the better, but with APML, treatment is started on "clinical suspicion because of the devastating consequences" bleeding can have.
When asked by Julie Struthers, representing the family on behalf of Leigh Day, about blood tests, she added: "If a patient is coming back and fourth with the same symptoms, in my opinion blood tests should always be done at that stage."
It was on July 26, after her bloods were examined by Alder Hey, she was diagnosed with a rare type of leukaemia, and despite a high recovery rate, the biggest risk is coagulopathy - excessive bleeding. The hearing heard how this becomes "more severe the longer it is left" and is the "crucial part" of treatment.
The Warrington teenager was transferred to Alder Hey hospital for specialist care before she was sent to the high dependency unit. She was told she would be having an operation on July 29, but her health quickly deteriorated.
The hearing previously heard how Katie's original management plan was not seen and there was a crossover team with oncologists and haematologists. However, on Wednesday, it was heard that patients with APML are classed as a 'haematological emergency'.
Dr Farrelly, from the Royal Hospital, said the issue is an "evolving picture" and fibrinogen levels can "drop dramatically". When asked about Katie's original care plan, which was not seen, she said she thought it was "potentially confusing."
The choice to use plasma alone would "not be sufficient enough to alleviate the risk of a bleed." When asked about the headaches Katie was complaining of, Dr Farrelly added that when reading the document after her death it made her "uncomfortable" and "when she complained of a headache, I knew how she died."
She went on to say that patients with coagulopathy, it "doesn't have to be fatal" as "management is vital" and had that bleed been treated earlier, on the balance of probability, Katie would still be alive. At this comment, the family watching in the courtroom were visibly upset.
When speaking about Alder Hey's care plan, she added the "initial plan could've been better" and there was "clear difficulty in the communication progress." She told the hearing once a patient starts bleeding, it will not stop until the correct clotting product is given.
She said it is "unusual" for an oncologist to be on care for a patient like Katie as they "should be managed by a haematologist, particularly in that first stage."
On July 29, after Katie deteriorated, scans showed she had a bleed on the brain and was rushed for surgery. The next day, further results showed there was no brain activity and a difficult decision was made to turn off the machines that were "keeping her alive". She died on July 31.
Earlier this week, both Alder Hey and Warrington admitted that there were " missed opportunities " and that "significant lessons" had been learnt as a number of things have been put in place since Katie's death. Mr Sion Davies, representing both hospital trusts, asked the independent witness on Wednesday if she was content with the trust's mitigation. She replied: "It's sad when a case like this highlights a need", but mitigation should be required for cross over care with APML patients.
On behalf of the family, Ms Struthers asked the coroner to make findings of neglect in Warrington for "a failure to diagnose" and in Alder Hey for a "failure to treat". She added bloods should have been taken before abnormalities presented on July 26 and Alder Hey failed to "monitor and manage" the basic "fundamental part of her treatment."
Requesting a narrative conclusion and prevention of future deaths report, Ms Struthers said cross cover arrangements at Alder Hey remain in place and "training hasn't been given." She went on to say Alder Hey is a "world class centre" and Katie was transferred from Warrington for that specialist care, so "surely it stands that specialist care is given."
She went on to say oncologists can care for leukaemia patients, but don't have the "specialism" to deal with APML patients and "action needs to be taken."
However, Mr Sion Davies said learning "has been extensive" and arrangements are in place such as a new document that better defines roles and complex needs. When speaking about staffing, he said: "In a perfect world maybe there would be different working arrangements, that's not the reality faced by the NHS and not the reality faced by Alder Hey."
He added further training is "planned" but the best way to deal with concerns would be a "private letter" as a prevention of future death report would "have no practical effect."
A conclusion is expected on Thursday as the inquest continues.
