There was ‘culpable human failure’ in the hospital care of a 12 year-old girl which ‘rendered her death unnatural’, the High Court has heard today (March 24). Victoria Olabode, from Rochdale , died at the Royal Manchester Children’s Hospital on July 15, 2019, after suffering a stroke. Her devastated family is now fighting for a new inquest to be held into her death. The youngster, who had Sickle Cell Disease, had been transferred there 13 days earlier. On July 5, three delays after her admission, she suddenly developed a severe headache and began vomiting. She was treated for her pain and discomfort but her mother had ‘persistently’ asked for a CT scan to be carried out, the inquest into her death was told. Yet this was not done until July 8, when Victoria suffered a ‘prolonged seizure.’ Get MEN Premium now for just £1 HERE – or get involved in our WhatsApp group by clicking HERE . And don’t miss out on our brilliant selection of newsletters HERE. Victoria suffered a second seizure later that day and was afterwards admitted to the hospital’s paediatric intensive care unit where it was found she had suffered an ischaemic brain injury. She was deemed to be brain dead on July 12 and three days later her ventilation was withdrawn leading to her death. At the inquest, which concluded at Manchester Coroner’s Court in April 2024, a coroner ruled she died of ‘natural causes.’ Concluding the inquest, which heard six days of evidence in December 2023 and February 2024, Area Coroner Zak Golombeck highlighted multiple failings in her care. He said he had found it was a ‘failure’ that a CT or MRI scan was not carried out on July 5 or 6 ‘when it was clear that Victoria was suffering serious neurological symptomatology’. However, he said that had a scan or scans been carried out at that time, it ‘would not have conclusively confirmed subarachnoid blood’, the medical term for a type of stroke caused by bleeding on the surface of the brain, as the CT and MRI scans carried out two days later didn’t do so either. He described the protocol for the MRI scan which was eventually carried out as ‘sub-optimal’ and said that ‘this too was a failure in the care.’ However, he said: “On the balance of the evidence following my analysis, I find that there is insufficient evidence to cross the threshold beyond speculation that Victoria’s death would have been avoidable with earlier imaging on July 6, 2019.” Mr Golombeck added: “On the balance of probabilities, there’s insufficient evidence that she would have avoided the terminal event on July 8 which caused her death on July 15. Whilst I have found failures in her care, none of these failures more than minimally contributed to her death on the balance of probabilities.” Police were called to Manchester Coroner’s Court amid angry scenes as Mr Golombeck delivered his findings. Today, the family (March 24) challenged the coroner’s decision at a judicial review hearing before a High Court judge. Victoria’s parents Victor and Elizabeth Olabode, and the coroner, were both present in the court for the hearing at Manchester’s Civil Justice Centre. A ‘central issue’ in the claim was whether ‘the clinical signs warranted a diagnosis of of Posterior Reversible Encephalopathy Syndrome (PRES)’ – neurological condition characterized by headaches, seizures, confusion – ‘regardless of a scan’ and how this would have affected Victoria’s treatment, the court heard. The judge was told the family contend that the coroner ‘fell into error, unreasonably so, in concluding, based on radiology, that no different treatment would have been undertaken.’ Christian Howells, representing the family said that ‘the radiology evidence is just one piece of the jigsaw’ and that ‘clinical judgement and neurological examination are other pieces of the jigsaw.’ “They also provide answers to the question of whether any other treatment could or should have been provided over the weekend” he said. He said there ‘was a failure by medical staff over the weekend to recognisie the importance of Victoria’s headaches.’ “The importance of what was going on was just not recognised. Had it been, a different course would have been followed” Mr Howells said. He said that PRES was ‘clinically indicated’ and that ‘appropriate management’ would have included earlier transfer to the high dependency unit and blood pressure monitoring. Setting out the grounds for the judicial review, he said that the coroner also ‘unreasonably disregarded’ the evidence of one expert ‘on causation’ and ‘put the causation test in his conclusion too high.’ “No expert in this case said the death was inevitable from July 5 onwards. No expert said nothing could have been done to avoid the catastrophic outcome on July 8, from July 5 onwards” he said. Concluding his submissions, he said: “Although Victoria did indeed die of natural causes, it was in circumstances where there was a culpable human failure that would have made a difference to the outcome, so that death was rendered unnatural” Sophie Cartwright KC, representing the Manchester University Foundation Trust (MFT), which runs RMCH, said ‘this was and remains a case of some complexity’ and that it was ‘very difficult’ to ‘cherry-pick parts of the evidence.’ She said consideration was given in the inquest to ‘differential diagnoses’ including PRES which ‘may have affected how Victoria was managed.’ There was ‘no public law error in the full context of the evidential picture that the coroner considered’ and there was ‘no absence or analysis or reasoning’, she continued. She said it was ‘clear (the coroner) had ‘given thought and weight to the evidence he received.’ “It is clear, if you read his findings of fact, he has had regard to all of the evidence” which, she said, included ‘not only factual evidence but expert evidence from multi-disciplinary experts, all of which he has considered with care.’ The findings he made were ‘not unreasonable’ and ‘it is not for this court to substitute findings of fact’ she added. Bridget Dolan KC, representing the coroner, said ‘the issue of whether there was a failure to diagnose PRES does not appear in any of the documentation, to have been an issue’ before experts were instructed by the coroner and that it was ‘not acknowledged by the trust to have been a shortcoming.’ She said that Mr Golombeck had ‘investigated all the shortcomings they (the trust) acknowledged and the potential causation element.’ She told the judge, Mrs Justice Hill, that ordering a fresh inquest was not the only option open to her if she did find there had been any error in law. The judge ‘emphasised her condolences’ to the family and thanked all parties for ‘such an efficient and dignified hearing.’ She said the ‘difficult and complex’ case required some ‘careful thought’ she would deliver her judgement at a later date.

Original source: gb