The tragic death of a teenage girl who was suffering from a rare form of leukaemia could have been prevented and was the result of medical neglect, a coroner has said.
Katie Wilkins, who was just 14, from Warrington died on July 31, 2020 after suffering an intracranial haemorrhage as a result of her acute promyelocytic leukaemia (APML). She had no significant medical history and had fallen ill only a month previously.
Her inquest, which began on Monday (May 23) at the Gerard Majella Courthouse in Bootle, saw coroner Kate Ainge conclude today (May 26) that her death was avoidable, the Liverpool Echo reported.
Ms Ainge said a proper clinical review and blood test could have led to an earlier diagnosis and the correct treatment.
The teenager’s symptoms began with unbearable pains when visiting her sister in London in June 2020. On June 30 she was taken to A&E in Warrington, where they found an unusual abscess and a course of antibiotics were prescribed.
The family were advised the healing process would take time and she was given a second course of antibiotics at a follow-up appointment on July 2.
Katie, who went to Bridgewater High School, went to hospital five times and was in a lot of pain. She began to get shooting pains in places such as her abdomen which stopped her sleeping at night.
On July 14, Katie had made no improvement. She was given a PEW – a Paediatric Early Warning Score, used nationally to predict early deterioration – score of two, which was mistakenly recorded as one.
Ms Ainge said a higher score would have led to an escalation of care and four hourly observations should have been made.
Katie was given a bed at Warrington’s paediatric ward with the possibility of surgery the next day, but instead was discharged with no blood tests taken and given an MRI.
Then, on July 26, Katie collapsed at home and continued to decline.
She was stabilised at Warrington Hospital and transferred to Alder Hey, where she was confirmed to have APML. Her fibrinogen levels were recorded as less than one, which should have been acted on immediately.
An independent health expert, Dr Cathy Farrelly from the Royal Liverpool Hospital, gave evidence on Wednesday saying the unusual nature of the abscess, usually found in elderly people, should have led to a clinical review and a blood test.
If left untreated, such an abscess builds in risk and is more difficult to correct. She said it should have been treated on the basis of suspicion.
Katie also had a mild headache which, together with her other symptoms, should have been a red flag that something was wrong.
A complex rota system and a lack of haematologists at Alder Hey also prevented Katie receiving necessary treatment, the inquest was told.
On July 29, Katie suffered an intracranial haemorrhage and, after surgery, was declared brain dead with her parents by her side. Ms Ainge said Katie was a vulnerable young girl and there was a failure to give her basic medical attention.
APML has a high mortality rate if not treated properly in the first few days. Ms Ainge said it was “more likely than not” that her death could have been prevented with the right care.
The rare form of cancer does have a high recovery rate but comes with a severe risk of coagulopathy – excessive bleeding.
As a result of the investigation into Katie’s death, Ms Ainge said further training and accountability would be given to staff to reduce the margin of human error.
A new rota system has been put in place at Alder Hey Hospital for those with complex needs, the inquest was told. The coroner added that Alder Hey had suffered from a national lack of resources, including a shortage of haematologists.
The hearing was told the issue had been escalated to those funding NHS trusts, the Secretary of State and ministers for health.
