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.
We would like again to offer our sincerest condolences to Alice's family.
The inquest heard a detailed timeline of the events that unfolded last year:
Alice was taken to hospital for MRI scan to find the cause of severe headaches.
She is given general anaesthetic due to her anxiety, but blood pressure and pulse were not checked.
MRI scan begins, Alice's heart rate fluctuates so procedure stops and starts several times.
MRI scan finishes, Alice taken to intensive care as her condition deteriorates.
Alice is transferred to Bristol Children's Hospital, she spends three days in critical care.
Alice suffers multiple organ failure and is pronounced dead.
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:
It's exhausting, mentally, physically, financially, in every way, we've been drained. Hopefully we can pick up something and have a Christmas for our children again, last year we didn't have one, muster up some of Alice's spirit, she was the one who enjoyed Christmas the most. And we just hope we can give our children some sort of excitement this time of year now this is over.
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.