Doctors did not spot teenager's fatal ulcer

But senior coroner Jennifer Leeming concluded that Sean Akdemir died as a result of an undiagnosed gastric ulcer, that had occurred naturally, perforating into his chest cavity through a diampragmtic hernia.

She said a complication of the surgery, which Sean had undergone at Alder Hey Children’s Hospital in July 2014, that led to the hernia and the non sterodial anti-inflammatories Sean was prescribed for the pain afterwards did contribute to the ulcer perforating.

One of the questions Sean’s mum Maureen Akdemir had raised at the beginning of the inquest was why the results of a CT scan done six days before Sean’s death had not been reviewed by the consultant who had ordered it on December 2.

But Matthew Jones, the consultant paediatric surgeon at Alder Hey who operated on Sean in July to strengthen his diaphragm, told Bolton Coroners Court that had he reviewed the results of the CT scan sooner, he may have called Sean back to hospital to repair the hernia it had identified but that the scan did not show the ulcer.

Sean was 16 when he collapsed at his Springfield home and died a short time later at Wigan Infirmary on December 16, 2014. Mrs Akdemir told the court that he had been experiencing abdominal pain since the surgery but they had been told this was just part of his recovery.

Mr Jones said when he saw Sean on December 2 he was “experiencing symptoms he had not expected months after surgery”.

He said: “The operation was intended to strengthen Sean’s diaphragm at the front but at the back it was still weak and floppy.

“A hernia or eventration of the diaphragm does not normally lead to pain so I ordered a CT scan to see where the diaphragm was weakened to plan what to do next and to see what was causing Sean’s pain.

“I did not suspect he had a gastric ulcer and this did not show up on the CT scan. Had I received the results of the scan earlier I would have recalled him to hospital and operated to strengthen his diaphragm. It is unlikely I would have seen the ulcer and I was not looking for one.”

The scan was done on December 10 and Mr Jones intended to review the results before meeting Sean again on December 19. The scan showed Sean had a diaphragmatic hernia that his stomach and some of his bowel had herniated through.

Mr Jones said: “I feel really awful about this case. I feel I did let Sean and his family down. My biggest regret is I did not examine the possibility that he had a gastric ulcer.

“When I saw Sean in December he seemed in broadly good health. If I was informed that his condition had deteriorated afterwards, as I have heard in the evidence it did, I would have admitted him to hospital to find the cause of the pain.”

He told the court it was difficult to tell when the ulcer had started to form but that it could have been before the surgery on his diaphragm in July 2014 and would explain the pain in Sean’s back which had initially led to him seek medical help.

He said: “The problem with Sean’s diaphragm acted as a tragic red herring which masked the gastric ulcer.”

The court heard that a Sean’s case was complex and it was extremely rare for a 16-year-old to be suffering from a gastric ulcer.

But John Orr, a retired consultant paediatric surgeon who gave evidence as an expert witness, told the court that the non-sterodial drugs Sean had been prescribed after his surgery would have contributed to the ulcer perforating.

He also said: “Sean’s stomach was in an unusual position because of the hernia and this would have contributed to the ulcer perforating because his stomach wouldn’t be draining as well as it should have been.

“If this was my case, I would have expected the radiologist to contact me straight away about the results.”

The court heard that the radiologist who wrote the report on Sean’s scan did not think it was necessary to contact Mr Jones straight away but he had expected him to review it in the next 24 to 48 hours.

The court heard that Alder Hey had a system for reporting results from radiology in place but it was not monitored as recommended by the Royal College of Radiologists and that many other hospital trusts failed to follow these recommendations as well.

Mrs Leeming said this was worrying and she would be writing to the Department of Health to advise them of this.

Dr Alistair Bint, a GP and expert witness, told the court that there was some evidence in Sean’s GP notes that he had a history of gastric problem.

He said: “This does not prove but adds credence to the possibility that the ulcer had been developing over a number of years.

“There had been some investigation into the possibility that Sean had an ulcer in 2010 but it appears that Sean had a good response to an anti-acid drug prescribed.

“Normally we would see a patient, and this is usually in people aged over 45, making regular visits to the GP with abdominal pain and they would not respond to the drugs prescribed as Sean did.”

Sean saw a GP, Dr Liam Hosie, the day before his death because he had been vomiting for several days and was sent home with some anti-sickness medicine but was told to go to hospital if things got worse.

Dr Bint said that some GPs may have admitted Sean to hospital with the symptoms he was experiencing but that Dr Hosie’s actions were in keeping with what many GPs would have done.

Mrs Leeming recorded a narrative conclusion that Sean had died as a consequence of a naturally occurring undiagnosed gastric ulcer the perforation of which was precipitated by the post surgical administration of non sterodial anti-inflammatory drugs and by a complication of the surgery itself.