Inquest into the death of a baby

May 11, 2021

Sufiyan Rana represented the family of Lily Mae Teale (10 months old) at a 3-day multi party inquest at Doncaster Coroners Court following which the Coroner made two Regulation 28 reports relating to the walk-in centre and the treating GP.

On 22 November 2017, Lily woke up at around 4.30am crying with a high temperature and diarrhoea, shaking, vomiting and panting. Her mother called NHS 111 and reported these symptoms and was directed to attend her GP within 12 hours. Later in the morning, Mother called her GP surgery who directed her to a Same Day Health Centre (SDHC) because they did not have an appointment. She attended this centre and saw a locum GP for 11 minutes and despite alerting the locum GP to the symptoms, a misdiagnosis of gastroenteritis was made, and she was given a general safetynet advice. By the afternoon, Lily’s presentation significantly deteriorated. Her lips went blue, skin became mottled and her breathing laboured. Despite being taken to hospital she suffered seven cardiac arrests and died later than evening with Meningococcal septicaemia.

Between 4-6 May 2021, the inquest took place at Doncaster Coroners Court before Assistant Coroner Slater. Including the family there were six interested parties, namely NHS Digital, GP Surgery, Same Day Health Centre, Dr Saward, Yorkshire Ambulance Service. 17 witness statements were submitted and nine witnesses gave oral evidence including a GP expert and an Intensive care expert.

Having heard the evidence, the Coroner gave a narrative conclusion. She preferred the evidence of the mother to that of the treating locum GP and ordered two Regulation 28 reports to be made against SDHC to the Care Commissioning Group (CCG) on the grounds there was no evidence of formal reporting of an underperforming GP and against the locum GP to the General Medical Council (GMC) on the basis that the physical examination was deficient and the note keeping lacked necessary detail.

The inquest received national news coverage including in the Daily Mail, the Sun, and the Mirror.

Sufiyan Rana is a specialist Personal Injury, Clinical Negligence and Inquest Barrister. He sits as a Deputy District Judge on the Northern Circuit and as a Fee-Paid Tribunal Judge in the mental health jurisdiction.

He was instructed by Amy Fiddler from Howells LLP.