'Happy and cheeky' teen could have been diagnosed earlier at QMC, inquest concludes

The complication that killed a 16-year-old boy after a scoliosis surgery at a Nottingham hospital could have been diagnosed earlier, a coroner has said. Finlay Topham, 16 and from Grantham, died on March 10, 2023, from complications following a scoliosis surgery at the Queen's Medical Centre, part of the Nottingham University Hospitals NHS Trust, in Nottingham.

The Nottingham Forest fan had recently been diagnosed with scoliosis but also suffered from Duchenne muscular dystrophy, a genetic disorder which causes muscle degeneration and weakness that he had been diagnosed with at three years old. Finlay started developing necrotising enterocolitis following his surgery.

Necrotising enterocolitis is a "rare and very serious condition that carries a very poor prognosis" and consists in the inflammation and death of tissues in the intestine, an inquest into Finlay's death was told. The delay in diagnosis came despite Finlay's family raising concerns about his state.

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Coroner Elizabeth Didcock, who led the coronial investigation into Finlay's death, said: "I accept evidence that he was very poorly and this was not recognised by the members of staff. It is unfortunate one of the doctors did not speak directly to the paediatric surgeon.

"He relied on his junior to do this and to record the outcome of the discussion, which I find led to miscommunication." Finlay also developed sepsis in response to the inflammation in the body - this was managed "appropriately" and antibiotics were prescribed.

Coroner Didcock told the court on Friday, June 28, that Finlay's care overnight was "excellent", with multiple discussions between the on call consultant and PICU staff. A CT scan then showed necrotising enterocolitis and bowel ischaemia.

Coroner Didcock said: "I find that there was an opportunity to make an earlier diagnosis. The diagnosis would have been very important for the family to understand what was wrong and to be aware of the seriousness of the situation.

"However, I accept that there was nothing additional that could have been done that could have changed the outcome once the diagnosis was made. I understand that once the enterocolitis was observed, the treatment was appropriate.

"Whilst there are issues of care in this case leading to a delayed diagnosis of the condition, I have not found any issues of care after the diagnosis was made." Finlay's Duchenne muscular dystrophy led to the development of severe scoliosis requiring surgical intervention, which was performed on March 2 and was followed by abdominal sepsis, necrotising enterocolitis and bowel ischaemia.

The delay in the diagnosis of the necrotising enterocolitis did not, however, lead to a more than minimal delay in appropriate treatment being provided, the hearing was told. Unfortunately, Finlay continued to deteriorate because of the severity of the necrotising enterocolitis despite supportive treatment.

Coroner Didcock said: "I am satisfied that all that has already been done and all that is planned by the trust is sufficient. I welcome particularly the paediatric escalation policy and I hope it can be used across the trust.

"I also welcome the family activation rapid response project which will facilitate parents rising concerns about their children's condition." Dr Didcock concluded the proceedings by extending her condolences to Finlay's parents and sister, who were present at the hearing.

Finlay’s family said: "Finlay our son and brother always came with us no matter where we were going or what we were doing. He loved Nottingham Forest, Nottinghamshire County Cricket and going on holiday to Scarborough.

"He was his dad’s wingman, they were always together especially if his mum and sister were taking too long shopping or talking. Finlay always had a cheeky smile on his face and made sure everyone had a smile on their face from his one liners.

"He was taken from us far too soon and we will always miss him." Speaking on behalf of the family following the inquest, their lawyer, Linda Millband, from law firm Thompsons Solicitors, said: "This has been a very difficult ordeal for Finlay’s family who have heard evidence throughout the inquest of failings in the care that he received in the days leading to his death.

"Whilst they feel that they still have many unanswered questions, they are grateful to the coroner for their time, and relieved by their findings that there had been missed opportunities to diagnose and treat his condition sooner, as well as a failure to listen and respond to their concerns about his deteriorating condition.

"They are pleased that the trust has accepted a number of recommendations made following Finlay’s death, and it is their hope that immediate action is now taken to act upon those recommendations so that no other family should suffer such a traumatic and difficult loss as they have moving forward.

"Finlay’s family are very grateful to the press for their sensitive reporting of this matter. They miss him dearly, and want him to be remembered as a happy, cheeky lad, who lit up any room with his smile and anyone who met him.

"They hope to keep his memory alive through their ongoing fundraising activities." Dr Alun Harcombe, Deputy Medical Director at Nottingham University Hospitals NHS Trust, said: "We would like to share our sincere condolences with the family of Finlay Topham.

"We have investigated the care given to Finlay and fully accept the findings of the coroner given in court. As a Trust, we are committed to putting in place improvements to strengthen both our approach to the care of our patients, and of the appropriate support families should expect from us."

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