Annabel Greenhalgh inquest highlights 'missed opportunities' as parents call for 'lessons to be learned'

An 11-year-old girl who passed away just hours after being discharged from A&E with constipation died from natural causes, an inquest ruled. Annabel Greenhalgh suffered a cardiac arrest brought upon by a cardiac arrhythmia while in the bathroom of her Warwickshire home.

Assistant Coroner Richard Brittain ruled that it was difficult to say that there was a direct correlation between Annabel’s care and her untimely death.

The youngster was suffering with intestinal atresia which caused her a great deal of pain - but her death was considered to be relating to natural causes.

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Colonel Douglas Bowley, an emergency general surgeon, suggested that her death was brought on by cardiac arrhythmia but was not able to say whether it was induced by straining.

He said: “That process is extremely rare but potentially possible.”

On whether Annabel would’ve stood a better chance of survival, Colonel Bowley said: “I don’t think she’d have direct continuous cardiac monitoring. On a standard ward real time monitoring of the heart is not needed. I do think she would have been observed. Considering she had normal life signs and blood tests, it would be several hours between each observation.”

Coroner Brittain summarised Annabel’s condition at the time, saying: “The next day more concerns were raised and the pain had worsened.

“That reflected the significance of the pain and Annabel was able to well judge her pain and she judged it quite severe 8/10. She was seen by an A&E doctor. She had an x-ray of her abdomen undertaken which was very difficult to interpret.

“We know that the x-ray in retrospect showed unusual findings of where faecal loading would be seen. Even the radiologist didn’t recognise that so i think it’s not surprising that the surgical doctors found it was faecal loading.

“Clearly there are issues with recruiting middle grade surgical doctors. It’s not clear how the decision to discharge was made. We know that the junior doctor had discussed it with the middle grade doctor.

“She was discharged from A&E having not being seen by a middle grade surgeon directly.

“We know that the surgeon involved here Mr Marriott had no knowledge. Mr Marriott has considered what he would have done, contacting Birmingham Children's hospital.”

He added: “She would have had ongoing observations. Mr Singh sets out that she would have had intravenous medication. To a certain extent her pain did improve, but not resolve.

“I think a lot of that was the embarrassment that she thought was constipation. We know now that constipation was not the cause of her pain. It does seem that she had some improvement, clearly the pain didn’t worsen in A&E but it did not resolve.

“At home she attempted to pass stool and clearly reflected on what she had been told that she had been constipated.

“It’s very speculative on what would have happened in regards to a cardiac arrest. It’s unlikely she would have had ongoing electrical monitoring. It’s likely she would have had regular observations separated by several hours.

“She would’ve been there during the night period. We know that she was found at home next to the toilet so it’s likely that she was on the toilet trying to pass stool thinking she was constipated.”

On his ruling Coroner Brittain added: “My view is that it’s not possible to say that she would’ve survived cardiac arrest in hospital. It’s a very difficult point to consider. There isn’t enough evidence to suggest that she would have survived.

“There were clearly issues that have been categorised as missed opportunities. So it’s possible that she would have survived in the hospital, but I don’t think it’s probable.”

He added: “Arrhythmia was the underlying cause of her cardiac arrest. My thoughts are that we have enough evidence to convince me of an arrhythmia.

“I can conclude that she died of an arrhythmia. To have such significant medical background issues, it’s the whole context of the visits to A&E and her ongoing pain.

“The conclusion today is one that is difficult to consider. Given the medical cause of her death, it’s difficult to say there is a direct correlation between the care and her cause of death.”

Coroner Brittain marked Annabel’s death as a cardiac arrest brought on by cardiac arrhythmia, categorising it as a natural death.

Outside the coroner’s court the family’s lawyer Emma Rush read a statement which read: “Sadly the inquest has highlighted worrying issues in the care provided to Annabel prior to her death.

“It’s now vital that lessons are learnt to help improve safety and prevent other families going through the terrible suffering that Annabel’s family has.

“We will continue to support Josie and Craig at this time.”

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