A two-year-old boy died after a brain tumour went undiagnosed for several weeks, a British inquest has heard.
Max Earley fell ill in August 2012 but despite being seen by several doctors and being transferred to another hospital, his tumour was not spotted until just days before he died the following month.
An inquest at Westminster Coroner’s Court yesterday heard how his parents felt they were literally “watching him die” as he got more and more ill, but it was only when he was rushed to Great Ormond Street Hospital that the tumour was diagnosed.
Despite an operation to remove some of the tumour, Max never recovered and died on September 28, 2012.
The court heard that a series of things “went wrong” between Max being admitted and finally being diagnosed – including an original CT scan being read incorrectly by a radiologist.
Parents felt they were literally watching him die
Max, who was 27 months old when he died, first became ill in August 2012 when he started vomiting repeatedly. After several visits to his GP, his mother Caroline Earley took him to Accident and Emergency at Hillingdon Hospital in Uxbridge, west London, where he was admitted. The inquest heard that the paediatrician who saw Max suspected he might have a brain tumour and ordered a CT scan, but it was incorrectly deemed clear by a radiologist.
Another test to look at a possible gastro-intestinal cause returned an abnormal result, so attention shifted as to the cause of his illness as doctors suspected Max had a hernia.
The youngster was due to have an MRI scan of his brain to double-check whether he had a tumour, but that was put on hold as doctors focused on gastro-intestinal causes.
Max’s treatment was passed to Chelsea and Westminster Hospital, where doctors tried to find the cause of his illness. But as the weeks passed, his condition continued to worsen, and his parents described watching him slowly deteriorate.
Mrs Earley, from Harefield, near Hillingdon, told the court that as his condition worsened, she told doctors she feared her son was dying. As they still struggled to find the cause, she said: “I knew he was so seriously ill, something had to be done, we couldn’t waste any more time.”
Max was admitted to the Chelsea and Westminster Hospital in mid-September, by which time he was described as pale, weak, moaning and sensitive to light.
On September 23, 2012 the two-year-old’s weight had dropped to the same as when he was 12 months old and he would cover his face with a teddy bear to avoid light, Mrs Earley said.
Max’s father Vladimir Earley described how when Mrs Earley left the hospital to return home that evening, their son became agitated and was trying to rip out his tubes, as well as tearing at his hair. He said his son’s eyes were rolling back in his head as if he was in a deep sleep, yet he was agitated and “thrashing around”.
Medical staff raised the alarm between 8pm and 9pm that night and Max was rushed to Great Ormond Street Hospital in the early hours of September 24, where a brain tumour was diagnosed.
Despite an operation to “de-bulk” the tumour, Max never recovered and died on September 28.
At the start of the inquest, which is due to last two days, Coroner Dr Shirley Radcliffe told the court that the issues in the case were “fairly clear”.
“We know what went wrong and the problems are, as I see it, one, the CT scan was incorrectly read, that was the first thing that went wrong,” she said.
“The second thing that went wrong was that there was no consultant-to-consultant communications between Hillingdon and Great Ormond Street.
“The third thing that went wrong was that there were too many doctors involved, too many teams, too many doctors at different times,” she said, adding: “Things were lost in translation all the way through.”
Other blunders included a communication failure about the need to carry on suspecting brain “pathology” for Max’s illness after the suggestion of a gastro-intestinal problem was raised, and also the failure to push for an MRI scan of his brain, the coroner said.