Corby family seeking answers at baby daughter's inquest
A Corby family hope an inquest into their daughter's death will resolve the questions they have "never been given answers" to.
Jorgie Stanton-Watts was born without a pituitary gland, which produces hormones, and had a reduced immune system as a result.
Three doctors at her inquest told coroner Philip Barlow that the 23-month-old girl was a "high-risk patient" who could become unwell "very quickly".
Over the course of her life, she was admitted to hospital often; the last occasion was in October 2016.
The inquest into her death opened yesterday to establish how her condition deteriorated to the point she ended up dying after being rushed to a hospital in Leicester from Kettering General Hospital.
A pathologist recorded her cause of death as “multiple organ failure, the underlying cause is not ascertained”.
"This inquest is our chance to be heard and listened to at last; and for Jorgie we need to be heard," said the families in a statement read out at the inquest.
"What we want out of this inquest is for no family to be put through what we had to watch and endure over the last two and a half years.
"For that to happen those involved in her care on that last admission need to take responsibility, be made accountable and above all be honest.
"If this does not happen, no plan put in place to try and prevent another death will work as it will be based on lies.
"You can only move on and make changes with all the relevant facts.
"There were a number of questions we asked about what had happened at Kettering and up until now, we have never been given answers. Hopefully at this inquest we will get these.
"We would also like police and the hospital to review the way investigations are carried out and being more mindful that it is grieving parents you are dealing with.
"And also consider the length of time it takes for investigations to be completed and in a more sensitive way.
"Finally we feel families should be informed and made aware of disciplinary action to be taken against any persons found at fault and that their names should be made public outside inquests.
"Too much is kept under wraps, that is why Jorgie's was not the first child death at Kettering and will not be the last."
Jorgie was admitted to KGH on October 1, 2016.
Dr Rao, a consultant paediatrician on the ward at the time, told the coroner that on October 2 she was not concerned about Jorgie's condition because she “looked well” and “was not showing signs of a current or impending adrenal crisis”.
A hydrocortisone IV was withdrawn as Dr Rao had “no clinical concern” - when asked why the IV was withdrawn, Dr Rao replied: “I wouldn’t have, with the benefit of hindsight.
“I took that decision because she looked well.”
She added: “She had a temperature and increased heart rate but she looked well and water levels were fine.”
An increased heart rate and temperature were common because of Jorgie's pre-existing condition.
Dr Rao: “Had I been really worried about her condition I would have documented it in the notes.
“My feeling was she was on a high dose of hydrocortisone, which I don’t believe she required at that moment.”
“I accept fully that I should’ve explained the rationales in my notes.”
Dr Marinova, another consultant paeditrician at the time, saw Jorgie in the morning on October 3.
She was asked by coroner Philip Barlow why the hydrocortisone drip was not restarted on that day.
"Now we know what we know it would have been a reasonable move," she replied.
"At that point she looked better and had started on treatment, she was tolerating feeds.
"I didn't think I needed to change anything; I thought she was getting better."
The inquest continues.