Toddler died from rare form of kidney cancer after signs were repeatedly missed by doctors, FAI finds

A toddler died from a rare cancer after signs of the illness were repeatedly missed by doctors.

Jessi-Jean MacLennan died at Glasgow’s Royal Hospital for Children in November 2019 aged just 19 months following a battle with a rare form of kidney cancer.

Signs of the childhood condition were missed by medical professionals despite Jessi’s mum Sara doing “absolutely everything she could to try and get the help her daughter needed from the doctors”.

A Fatal Accident Inquiry into the child’s death found that if Jessi had been properly examined “cure was not just possible but probable”.

Mrs MacLennan first noticed that Jessi’s appetite had decreased and that she had a high temperature in July 2019. She took the one-year-old to Culloden surgery in Inverness where she was given antibiotics for an eye infection.

Sara followed up with health visitor Linda McLennan in August 2019 citing concerns about Jessi’s weight loss and eating habits and was referred to a dietician.

A “lump” began protruding from the left side of Jessi’s stomach in October 2019 and a large blood clot was found in her nappy.

Jessi was then admitted to the paediatric ward at Raigmore Hospital as an emergency attendance and diagnosed with constipation by Dr Bhutto. He ruled out the need for an abdominal x-ray and prescribed a laxative.

As symptoms were continuing, Sara took Jessi to the GP on November 6 where she was seen by Dr Toby Gilbertson. He was unable to physical examine her due to her condition and referred them to the Paediatric Assessment Unit at Raigmore Hospital later that same day.

Jessi, who was described as ‘crying and irritable’, was then assessed again by Dr Bhutto on November 6, 2019. She was found to have elevated blood pressure but no further investigations were considered.

It was found that she had a “mass” and was tender on her left side which was put down to constipation. The doctor didn’t request any imaging to be taken in respect of the mass before she was discharged.

Jessi collapsed at home on November 15, 2019, after vomiting. She was described as “blue, cold, unresponsive and exhibiting agonal breathing” by paramedics.

An ultrasound revealed a tumour on Jessi’s left kidney later diagnosed as a Wilms’ tumour – otherwise known as nephroblastoma. She began emergency chemotherapy but, despite receiving maximum organ support, her liver was failing.

Jessi suffered a cardiac arrest on November 25 and passed away.

The medical cause of death was ruled as “complications of left nephroblastoma and associated therapy”.

At the inquiry, expert witness Dr Norman Wallace stated that he believes Jessi should have been referred for specialist treatment at the start of October 2019 when she presented as “very unsettled”. Professor Hamish Wallace told the inquiry if Jessi had been properly examined “cure was not just possible but probable”.

He stated that delays in Jessi’s diagnosis significantly contributed to her death.

Both experts agreed that there were at least three opportunities to correctly diagnose Jessi between October 3 and November 6.

NHS Highland told the inquiry they had taken steps to improve their paediatric care following Jessi’s tragic death.

In her ruling, Sheriff MacDonald said: “Professor Wallace’s evidence was clear: Wilms’ was a perfectly treatable disease once diagnosed; it was curable; and in Professor Wallace’s opinion if diagnosis had been made at any of the ‘missed opportunities’ from October 3 2019 until November 6, it was his view that cure was not just possible, it was probable.

“The evidence clearly shows that Mrs MacLennan did absolutely everything she could to try and get the help her daughter needed from the doctors. Mrs MacLennan could have done no more than she did for Jessi.

“All participants in the inquiry recognised the enormity of the family’s loss and I extend my deepest condolences to Mr and Mrs MacLennan and the family.”