Care of teenager who died after surgery 'poorly planned'
Amy Allan, 14, died in hospital after an operation to correct the curvature of her spine.
The care of a 14-year-old girl who died after undergoing spinal surgery at Great Ormond Street Hospital (GOSH) was "poorly planned", an inquest has found.
Amy Allan was recovering after an operation to correct curvature of her spine when she died at the London hospital in September 2018.
The youngster, from Dalry in North Ayrshire, was taken off a ventilator the day of her operation but died 23 days later.
She was removed from the ventilator at 11.20pm but did not receive ECMO, where blood is oxygenated outside the body, until the following morning.
On Thursday, a coroner at St Pancras Coroners Court in London ruled out neglect but said there was a lack of awareness, no plan for her post-operative management and no single clinician taking responsibility.
Giving a narrative verdict, Coroner Edwin Buckett said: "I find that that evidence taken with all other evidence in this case and the test for neglect is not established.
"Looking at the evidence as a whole I can't make a firm conclusion that extubation or the delay in ECMO caused or materially contributed to her death.
"I do, however, find that there was no prior plan set out by GOSH for the management of Amy post-operation.
"She was in any view a rare, complex, and high-risk case. ECMO should have been in the forefront of those involved in her post surgery care.
"I find that there was a lack of awareness with no single clinician taking responsibility for her care. The overall impression is that no-one was in overall control.
"The operation on September 4 set in train a sequence of events which caused her death. She was not able to withstand the effects of surgery and its aftermath upon her.
"Amy would not have died had the operation not taken place."
Reading a statement outside the court, Amy's mum called for a full investigation by the Care Quality Commission into her death.
The teen had been diagnosed with Noonan's syndrome, a genetic condition affecting her heart and lungs.
She also suffered from hypertrophic cardiomyopathy - an unhealthy thickening of her heart muscle, and pulmonary hypertension, both of which increased he risk of cardiac arrest from being on a ventilator after surgery.
'I find that there was a lack of awareness with no single clinician taking responsibility for her care'Coroner Edwin Buckett
Leigh Allan said: "Amy's death was senseless and unnecessary caused by carelessness and neglect.
"At the very least we hoped GOSH would investigate what happened and swiftly make changes to the numerous institutional issues which arise to ensure no other family would find themselves in our position.
"Instead they sought to diminish and dismiss our concerns at every turn.
"We do not want an apology, their time to be open, honest, and transparent has passed. Any apologies we receive now are hollow and simply because they have been caught.
"We want GOSH to tell the truth in all aspects including their attempt to cover up and the reasons why. We want accountability - nothing less is acceptable.
"We want the people who are proven to have purposefully omitted or lied about crucial information to suffer the consequences for their deliberate actions.
"We want a full investigation by the CQC and any other governing body to ensure that a hospital like GOSH - a clinical centre of excellence where the sickest children go is safe.
"To finally show us and more importantly Amy the respect we deserve and going forward commit to their policy to 'resolve complaints in an open, honest and positive manner'."
Paying tribute to her daughter, she added: "Amy was a complete goofball with a heart of pure gold.
"She has an amazing smile and an attitude to life we all envied. She was such a loving wee person, always so generous with her smiles, hugs, kisses and 'I love yous'.
"She is loved beyond all measure by Rick and I, Amy's wee brother Ryan and every single one of our family and friends.
"As her parents our lives have been left in pieces which we are desperately struggling to pick up for the sake of Amy's wee brother Ryan.
"We have spent the last year thinking of nothing but Amy's death and what we want to happen as a result of the inquest, when the only thing we want is Amy back and that can never ever happen. "