A delay in a 13-year-old girl getting a blood test was among a number of missed opportunities that contributed to her sudden death, a coroner has said.
Tanisha Baverstock, from Calne, died 24 hours after being diagnosed with lymphoma and collapsing in hospital.
The teenager had a persistent cough, breathlessness and weight loss when she was seen by her GP in December 2018.
The doctor diagnosed a chest infection and arranged a blood test for 2 January but it was not done until 18 January.
Ian Singleton, assistant coroner for Wiltshire and Swindon said the lack of “urgency” by the teenager’s mother in getting the blood test done was one of four delays in Tanisha’s care which contributed to her death.
“Tanisha had the blood tests carried out some two-and-a-half weeks late,” he said.
“I am surprised [they] were not arranged with a greater sense of urgency.”
He also highlighted the failure of Salisbury District Hospital’s paediatric team to see Tanisha until four days after being contacted by the GP, who had reviewed her blood test results on 25 January.
The “inadequacy” of the examination carried out by a consultant on 29 January and their failure to examine an X-ray of the girl’s heart properly were also criticised.
“It is not the case that Tanisha’s death came about due to only one act or omission,” the coroner said.
“There were a number of missed opportunities for Tanisha’s condition to have been accurately assessed at an earlier date and for appropriate treatment to have commenced, which on a balance of probabilities would have led to her survival.”
‘Code red’ flag
The inquest, which was held in early March but adjourned because of the coronavirus lockdown, heard that after Tanisha was seen by the consultant on 29 January she was sent home with antibiotics and a further appointment in four weeks.
The “code red” flag raised by a reviewing radiologist was not acted upon until the following day, when Tanisha’s mother was told to take her to hospital.
She was admitted to Bristol Children’s Hospital that evening and a CT scan confirmed the presence of non-Hodgkin lymphoma. Tanisha died less than 24 hours later.
Describing her daughter’s last moments, Ms Baverstock told the inquest: “If I had known my daughter was going to die, I would have had chance to say goodbye – that was taken away from me.”