A 14-year-old girl from Torquay who died after being put under general anaesthetic for a routine MRI scan was let down by her medical team, a coroner has concluded.
Alice Sloman, who had a number of medical conditions, died three days after an appointment at Torbay Hospital in October 2018.
An inquest into her death at Avon Coroner's Court has today concluded "a lack of medical management" led to her death.
The coroner heard how the teenager was given an anaesthetic before the scan in October 2018 after becoming "extremely anxious" and "hypersensitive". Her blood pressure and pulse were not, however, checked prior to being anaesthetised.
The coroner told two hospital trusts “medical management was lacking” over their failure to diagnose a heart condition.
Both Bristol Hospital Trust and the Torbay Hospital Trust have since apologised and have already drawn up plans to work with each other more effectively.
The inquest heard a detailed timeline of the events that unfolded last year:
In light of her death, Alice's parents have set up a campaign which aims to change medical procedure and enforce more checks on the hearts of patients before they are anaesthetised.
Her parents spoke at the inquest:
They added: "We can move forward, we will never move on, but we will move forward."
Recording a narrative verdict the coroner said four medical causes contributed to Alice's death - mitochondrial disease, multiple organ failure, myocardial fibrosis and heart failure during the anaesthetic.