A teenager’s death from meningitis was contributed to by “neglect and gross failures in care” at the hospital where she was treated, a coroner has ruled.
Isabel Gentry, 16, was taken to Bristol Royal Infirmary after falling ill on 18 May and discharged four hours later.
Avon coroner Maria Voisin said there were gross failures in Isabel’s care at the Bristol Royal Infirmary.
She said a doctor who saw Isabel should have referred her case to a registrar before allowing her to be discharged.
The coroner also noted the doctor did not take an accurate history and diagnosis of viral gastroenteritis was not appropriate and underestimated her condition.
Ms Voisin recorded a verdict of death by natural causes, and called on the government to fund meningitis vaccinations for teenagers.
Isabel’s mother Claire Booty said the family believed Isabel would have had a “better chance” at a children’s hospital “given her illness is more prevalent in the teenage age group due to their physiology”.
She added Bristol Royal Infirmary failed to give Isabel a “thorough and logical” assessment and questioned whether the hospital had “the ability” to learn from her daughter’s death.
Isabel, known as Izzy, had been revising for AS level exams when she started to feel unwell on 18 May. She was taken to hospital, by ambulance, at 01:00 GMT but was sent home at 05:00.
Avon Coroner’s Court heard the teenager “could hardly walk to the car” when they left the hospital after the initial assessment.
The court heard there had been a possible case of meningitis at her school, St Brendan’s Sixth Form College in Bristol, a couple of weeks earlier and all students had been given leaflets explaining the symptoms.
Paramedic Gary White, who was called out on 18 May, said he had been told the patient might have meningitis but said he “couldn’t detect any major symptoms such as a rash or photophobia [an intolerance of bright lights]”.
However, Ms Booty said Izzy “kept asking for the lights to be turned down” in the hospital treatment room.
The inquest heard Izzy deteriorated over the day and another ambulance was called which took her back to the hospital at 17:30.
The consultant who treated Izzy diagnosed meningitis and told Ms Booty her daughter was “very seriously ill”.
The next day an MRI scan detected Izzy’s brain was swelling and she died on 20 May.
A spokesman for University Hospitals Bristol NHS Foundation Trust said it would “carefully consider” the recommendations the coroner made.
He said as a result of Isabel’s death a number of measures had been implemented, such as a reviiew of training for doctors taking patient histories and an updated system of early warning scores.
“Our deep regret is that these measures did not ensure that we took steps to prevent Isabel’s illness from developing to the point where it could not be treated. Our commitment is to learn all we can from her very sad death,” he added.
Izzy Gentry meningitis death: ‘Failings’ by Bristol Royal Infirmary