Parents told eight-year-old son’s test could have been saved by simple test
The parents of an eight-year-old boy broke down as a coroner concluded their son’s life could have been saved by doctors carrying out a simple blood test.
Callum Cartlidge, who was described today by assistant coroner David Reid as "a loving boy who was always happy", suffered a cardiac arrest at his home less than 24 hours after a visit to Worcester Royal Hospital.
The coroner has slammed the hospital for failing to properly assess the critically ill boy who was misdiagnosed with gastroenteritis and discharged by doctors.
During his concluding verdict on Friday, Mr Reid told the inquest into the youngster’s death his life could have been saved if doctors had carried out a standard blood test.
He said the results would have revealed Callum was having an undiagnosed adrenal Addisonian crisis linked to the rare Addison’s Disease.
Instead medics diagnosed him with gastroenteritis and allowed him to return to his home in Redditch, Worcs, with rehydration medication, Dioralyte.
He was sent home and died in his sleep on March 3, 2017.
Mr Reid told the inquest Callum’s death was caused by an Addisonian crisis resulting from autoimmune arenalitis, complicated by enteroviral gastroenteritis.
The Worcestershire Coroner’s Court coroner concluded that it had been a “failure” on behalf of medical staff not to carry out a blood test which may have saved Callum’s life.
As the verdict was read out Callum’s mother Stacey Cartlidge began to cry, while his father Ade had tears in his eyes outside the court building.
Mr Reid said: “Callum was a loving boy who was always happy and who loved football and school.
“He was very sociable and always wanted to play. His head teacher paid tribute to him as a lovable rogue.
“I find as a matter of fact, on the balance of probabilities, that the decision not to carry out a blood test and discharge Callum was not reasonable in the circumstances.
“Callum was in crisis on March 2 when he was admitted to hospital.
“If the blood tests had been performed at that time they would have confirmed that he was suffering from hyponatremia [low sodium] and hyperkalemia [high potassium] and would likely have led to a diagnosis.
“When the first blood tests were performed on March 3 that diagnosis was confirmed.
“If that diagnosis had been made on March 2 then treatment would have begun immediately and I think that if that had been done, on the balance of probabilities, he would have survived.
“I find that the failure to carry out blood tests was indeed a failure to provide basic medical attention.”
During the five-day inquest it was revealed Callum had begun suffering symptoms of the extremely rare Addison’s Disease, including painful legs, dizziness and sunken eyes in December 2016.
After visiting the GP for the second time in three days on March 2, Callum was taken from the doctor’s surgery to Royal Worcester Hospital after being diagnosed with dangerously low blood sugar levels.
On arrival at the hospital’s Riverbank children’s ward, he was seen by a junior trainee doctor who made a note to the registrar to “consider bloods” but the test were never carried out.
The coroner concluded that although not conducting blood tests was a failure, it did not amount to a gross failure or neglect on behalf of the hospital.
Addressing the blood tests, Mr Reid said: “Dr Dawson concluded that the overall picture of his condition should have been considered much more thoroughly.
“It was not reasonable to send him home."
After being discharged, Callum fell asleep with his mum on the sofa at home before she woke up at around 3.30pm and found him not breathing and with pale skin.
A family friend called an ambulance while medics advised the family to try and revive him.
He was transported to Worchester Royal Hospital, 23 minutes from his home, rather than Alexandra Hospital, just three minutes away, due to a directive from Worcestershire Acute Hospitals NHS Foundation Trust to move all seriously ill patients to Worcester.
Coroner Mr Reid said: “I find that on the balance of probabilities, by the time the paramedics realised that the situation was irrecoverable and that even if they could have taken him to the Alexandra Hospital the outcome would have been the same.
“According to Dr Dawson, Callum was already dead by the time the paramedics arrived. He died sometime between lying down on the sofa and the 999 call being made.”
The coroner told the inquest he was satisfied that Worcester Royal Hospital had taken steps to correct the failings which lead to Callum’s death, including alerting staff to Addison’s Disease and making sure they accurately record fluid.
At the conclusion of the hearing, he thanked the witnesses and Callum’s family.
Mr Reid said: “I understand how difficult it must have been to come along each day and hear evidence of how your son died.”
Callum leaves behind his twin brother Aiden, sister Makayla, five, and 13-month-old brother Laighton.
In a statement following the hearing read out by solicitor Caroline Brogan from law firm Irwin Mitchell, the family said: “We all miss Callum so much and life has never been the same for our family since his death.
“Callum died far too young and had his whole life ahead of him.
“Now we have to live with the fact that we will never get to celebrate those landmarks in life, such as him passing his exams, starting his first job, or getting married.
“The last few days have been an incredibly upsetting time as we listened to the evidence regarding how our son died.”
In a statement, the Worcestershire Acute Hospitals NHS Trust apologised to the family for the failures identified by the coroner.
“We would like to again express our deepest condolences to Mr and Mrs Cartlidge for the tragic loss of their son Callum and apologise for the failures described by the coroner.
“This has been an extremely distressing case for everyone it has touched, in particular Callum’s family but also our healthcare professionals who were involved in his care.
“Callum died after a viral infection triggered the sudden and unexpected onset of an extremely rare and undiagnosed condition.
“The inquest heard from a leading expert on that condition – Addison’s Disease – who said he had never before in his 25-year career seen the disease present in the way that it did in Callum.
"Doctors and nurses who dedicate their careers to the care of children rely on their skills, knowledge and experience to interpret a range of clinical signs and observations of the child in front of them to decide on the best course of treatment.
“Sometimes, despite our best intentions, the outcome is not what we anticipated.
“We will continue to reflect and learn from the coroner’s findings.”
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