The death of a much-loved and irreplaceable teenager was contributed to by the negligence of two hospitals, a coroner has ruled.
This follows the conclusion of an investigation at the Gerard Majella Courthouse in Liverpool into the death of Katie Wilkins, of South Warrington, who tragically died on 31 July 2020.
The 14-year-old was a patient at Alder Hey Children’s Hospital in Liverpool at the time and died after a catastrophic haemorrhage in his brain.
On Thursday, forensic assistant Katy Ainge ruled that the negligence on the part of Warrington Hospital and Alder Hey Children’s Hospital contributed to the death of the former Bridgewater High School student.
Katie was diagnosed with leukemia in July 2020 and died five days later. He attended Warrington Hospital on June 30, 2020 in pain and was diagnosed with an abscess.
The former Stockton Heath Elementary School student returned to Warrington Hospital several times during July 2020 with ongoing and then worsening symptoms such as pain, bruising and then fever.
The coroner heard how the medical staff did not do the basic blood tests that would have diagnosed the disease as early as their first care in late June.
Katie finally collapsed at home on July 26 and was taken back to Warrington. Finally, blood tests were performed that revealed that Katie had acute promyelocytic leukemia (PML), a rare form of blood cancer.
Katie was taken to Alder Hey for specialized treatment for her APML, and the research found out how APML’s risk is not cancer, but the high risk of bleeding.
The coroner found that Alder Hey did not provide basic and basic care to Katie, as he did not administer fibrinogen, a vital blood clotting drug needed to prevent the bleeding.
Katie suffered catastrophic bleeding less than 48 hours after arriving in Alder Hey, and despite urgent surgery, she never recovered.
Katie’s mother, Jeanette Whitfield, told the investigation that Katie had been “drastically disappointed” by health professionals.
She provided shocking testimonials in which she described Katie as a “smart, cheeky teenager with a lifetime ahead of her.”
Jeanette talked about how Katie had wanted to become a paramedic and how she liked to ride a horse, and added that losing Katie was like “losing a piece of my heart.”
Katie had a passion for horseback riding
Katie began suffering from gynecological pain in late June 2020, but after a visit to the GP was inconclusive, her mother took her to the A&E department at Warrington Hospital on June 30.
An examination revealed a major abscess, for which Katie was prescribed two courses of antibiotics. On July 7, the abscess did not heal and looked pale and exhausted, Jeanette said.
On July 14, at another emergency appointment due to the continuing intense pain, Katie was told she would need surgery the next day to drain the abscess.
A doctor decided not to do a blood test that day and Katie was sent home. Katie was expected to have a blood test before her surgery the next day, but the surgery was canceled.
Instead, Katie underwent an MRI and was given a follow-up appointment for August 18th. He was advised to take co-codamol for pain.
The investigation was told that if Katie had had a blood test at this time, she would have shown that she had APML, a rare form of leukemia, for which early treatment is vital.
On July 21, Katie attended her seventh interaction with Warrington Hospital for help with worsening symptoms.
Jeanette explained to the investigation how a consultant dismissed her concerns about Katie’s intense pain and fluctuating temperatures.
The mother felt that her worries about the worsening of Katie’s symptoms were not taken seriously.
On July 26, Katie collapsed at home and was rushed to A&E at Warrington Hospital. Blood samples were finally taken and he was diagnosed with leukemia.
She was transferred to Alder Hey the next day and placed in the high-dependency unit.
A bone marrow biopsy was planned to confirm the diagnosis for July 29 and Jeanette was told that there was an APML cure rate of 80 to 90%.
Her family was told that there was a high risk that Katie would bleed because her blood was not clotting properly, but that she would be treated with blood products.
This should have included a drug that specializes in blood clotting called fibrinogen.
Warrington Hospital
Jeanette told the investigation that Katie was talking and calling family and friends on the night of July 28th.
However, even though Katie’s fibrinogen levels dropped to what the coroner felt were levels in the “danger zone” since the afternoon of July 28, Katie was not given fibrinogen.
The coroner felt that monitoring and treating fibrinogen levels was a basic and fundamental part of APML treatment.
At 9 a.m. on July 19, Katie told her mother that she had a headache. He was initially prescribed paracetamol and later morphine, but it soon became so severe that he cried in pain, before collapsing.
A CT scan revealed that Katie had suffered a catastrophic brain hemorrhage.
Alder Hey admitted that a new headache is a symptom of a “red flag” bleeding, and the coroner found that Alder Hey should have taken urgent action at this time.
Katie underwent surgery and was put on life support, and when it became clear that Katie would not recover, she was removed two days later.
Katie died on July 31, along with her mother Jeanette, father Jonathan Wilkins, and sister Harriet Wilkins.
The coroner said he would issue a report on the prevention of future deaths to the Secretary of State for Health in relation to the fact that Katie’s APML, which is a hematological emergency, was managed primarily by the wrong Alder Hey specialty. .
Katie was managed for a critical period before her death by an oncologist with no experience in this rare blood cancer, and a treatment plan established by a hematologist was not followed.
The independent expert, Dr. Cathy Farrelly, told the investigation that it was almost unheard of for an oncologist to manage the condition.
Dr. Keenan, Alder Hey’s trusted hematologist, said that patients with APML managed by oncologists were of concern to him and that he had raised those concerns in trust after Katie’s death.
However, the coroner learned that, due to national problems in hiring hematologists, the trust finally decided to keep the same agreements.
The family expressed concern that this would mean that other children with APML could end up in the same situation as Katie, causing more preventable deaths.
Katie (right), with her sister Harriet
The coroner has acknowledged these concerns by raising this national issue directly with the Secretary of State for Health.
After the investigation was completed, Katie’s mother and father said, “It’s hard to believe that we’ve unnecessarily lost our funny, affectionate, cheeky, and adorable girl with a contagious smile.
“The loss of Katie has left a huge void in our family and will be in our hearts forever. We will never forget it.
“The day Katie was taken to Alder Hey and diagnosed with leukemia, she asked her mother if she was going to die and Jeanette said, ‘No, you’re in Alder Hey’s best hands.’
“We knew Katie was at risk for bleeding, but we relied on the specialist and first-class care of Alder Hey’s medical staff.
“But the morning she was taken to the theater because of a brain bleed was like something out of a horror movie.
“It is still so hard to believe that our daughter was so catastrophically disappointed by the medical staff in whom we placed our full trust.
“Even after Watie’s hospital was so disappointed with Katie, we thought Alder Hey’s staff were experts in treating our daughter with the utmost care.
“We thought that when we finally had a diagnosis, Katie would be fine, because APML is so treatable and the survival rate is very high.
“However, we were wrong and Katie was again disappointed by those responsible for her treatment.”
The family continued: “This research has exposed the full range of basic deficiencies in Katie’s care by both Warrington and Alder Hey Hospitals, and we are pleased that the care provided by both trusts has been recognized as negligent.
“The truth about how she died and making sure this never happens to another child has been a devastating journey for our family for the past two years, but it’s what Katie deserves.
“We are relieved that the ongoing concerns we have about the level of care that current and future children with APML will receive for lack of hematologists are being raised at the national level and will need to be addressed by the Secretary of State for Health.
“While nothing can return to Katie, we are happy that her legacy is to protect other children with leukemia.
Alder Hey Children’s Hospital (Image: Google Maps)
“We are grateful for the dedication of our legal team and the professionalism of the expert and forensic Ms. Ainge.
“We sincerely hope that Warrington and Alder Hey Hospitals will act on the changes that have been promised to improve care for children with leukemia.”
Julie Struthers, a Leigh Day lawyer representing Katie’s parents, said: Warrington as Alder Hey.
“It has been very distressing for her family to know that Katie’s death could have been avoided if she had undergone a simple blood test before or had just received the right medication.
“I …