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Teenage girl’s death prompts children’s hospital overhaul

Amy Allan, 14, died at Great Ormond Street Hospital following an operation on her spine.

Family: Amy Allan's family have called for a full investigation by the Care Quality Commission into her death. STV

A world-renowned hospital has made a number of changes to its practice following the death of a Scottish teenager.

However, the mum of Amy Allan has said the apology and amendments are “hollow” and “changes absolutely nothing” one year on from her death.

Amy, 14, was recovering from an operation to correct the curvature of her spine when she died at Great Ormond Street Hospital (GOSH) in London in September 2018.

The youngster, from Dalry in North Ayrshire, was taken off a ventilator the day of her operation but died 23 days later.

She was removed from the ventilator at 11.20pm but did not receive Extra Corporeal Membrane Oxygenation (ECMO), where blood is oxygenated outside the body, until the following morning.

In September this year, an inquest found that her care had been “poorly planned”.

A coroner at St Pancras Coroners Court in London ruled out neglect but said there was a lack of awareness, no plan for her post-operative management and no single clinician taking responsibility.

Following the inquest and subsequent Preventing Future Deaths report, on Tuesday the hospital apologised and outlined what action it has taken to address the concerns raised.

The hospital said it has improved the way clinical information is shared between different specialist teams to make sure staff “have as comprehensive a picture as possible when making complex decisions about a patient’s treatment”.

Staff now use a single log-in electronic patient record system to quickly access clinical information to have “the right information at the right time” instead of routinely having to use multiple systems.

It has also improved consultant availability and introduced a new process to make sure the care of patients, like Amy, who have both complex spinal and heart conditions is routinely considered by the hospital’s specialist joint cardiology committee.

Matthew Shaw, chief executive at GOSH for Children NHS Foundation Trust, said: “I’m deeply sorry that Amy didn’t get the level of care she should have had.

“We know there are things we could and should have done better and it’s our responsibility to learn from those.

“Our thoughts remain with Amy’s family during this extremely difficult time, while the hospital continues to reflect on what happened, considers the changes we have made so far and asks what more we could improve.

“Following a review of the events that led up to Amy’s death we have already made changes to practice.”

Mr Shaw added: “We will continue to look closely at the concerns raised by Amy’s family and the coroner’s findings to determine whether we can do more to get it right for our patients.

“Amy’s family feels the hospital has not been open or honest in dealing with their complaint. No family should feel that way, and we will redouble our efforts to build strong relationships of mutual trust with the patients and families we try our best to serve.”

Amy was diagnosed with Noonan’s syndrome, a genetic condition effecting her heart and lungs.

She also suffered from hypertrophic cardiomyopathy – an unhealthy thickening of her heart muscle, and pulmonary hypertension, both of which increased the risk of cardiac arrest from being on a ventilator after surgery.

Giving a narrative verdict at the inquest, coroner Edwin Buckett said that the case for neglect was not established, but stated: “I find that there was a lack of awareness with no single clinician taking responsibility for her care. The overall impression is that no-one was in overall control.

“The operation on September 4 set in train a sequence of events which caused her death. She was not able to withstand the effects of surgery and its aftermath upon her.

“Amy would not have died had the operation not taken place.”

Heart of gold: Amy was a volunteer with St Andrew’s First Aid.

In response to GOSH’s apology and changes to its practice, Amy’s mum Leigh Allan told STV News: “The apologies are now hollow.

“It is what it is, but it doesn’t change a thing. Their time to be honest and transparent has passed.

“That’s what they’ve been told to say by their legal team – there’s still no accountability, they’re still not admitting anything.

“It’s not acceptable and it changes absolutely nothing.”

Following the inquest’s conclusion last month, Amy’s family called for a full investigation by the Care Quality Commission into her death.

They want GOSH to “tell the truth in all aspects including their attempt to cover up and the reasons why”.

Mrs Allan said that she has “been in a fog” over the past few weeks following the anniversary of Amy’s death, but now “the fight goes on”.

She stated: “An investigation is ongoing. At the moment we have to keep clogging away.

“The fight goes on.”


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