Warrington and Alder Hey hospitals contributed to Katie Wilkins death, coroner rules

This follows the conclusion of an inquest at Gerard Majella Courthouse in Liverpool into the death of Katie Wilkins, from south Warrington, who tragically died on July 31, 2020.

The 14-year-old was a patient at Liverpool’s Alder Hey Children’s Hospital at the time and passed away following a catastrophic bleed on the brain.

Today, Thursday, Assistant Coroner Katy Ainge ruled that neglect by Warrington Hospital and Alder Hey Children’s Hospital contributed to the death of the ex-Bridgewater High School student.

Katie was diagnosed with leukaemia in July 2020 and died five days later. She attended Warrington Hospital on June 30, 2020, with pain and was diagnosed with an abscess.

The former Stockton Heath Primary School pupil reattended Warrington Hospital multiple times throughout July 2020 with ongoing and then worsening symptoms including pain, bruising and then fever.

The coroner heard how medical staff failed to take basic blood tests from which would have diagnosed the disease as early as her first attendance at the end of June.

Katie eventually collapsed at home on July 26 and was taken back to Warrington. Blood tests were finally taken which revealed Katie had acute promyelocytic leukaemia (APML) – a rare form of blood cancer.

Katie was transferred to Alder Hey for specialist treatment for her APML, with the inquest hearing how the risk of APML is not the cancer, but the high risk of bleeding.

The coroner found that Alder Hey did not provide basic and fundamental care to Katie as it failed to administer fibrinogen – a vital blood-clotting medication needed to prevent haemorrhage.

Katie suffered a catastrophic bleed less than 48 hours after arriving at Alder Hey, and despite urgent surgery, she never recovered.

Katie’s mum, Jeanette Whitfield, told the inquest that Katie had been ‘drastically let down’ by health professionals.

She provided harrowing witness evidence in which she described Katie as a ‘smart, sassy teenager with her whole life ahead of her’.

Jeanette spoke about how Katie had wanted to become a paramedic and how she loved riding horses, adding that losing Katie was like ‘losing a piece of my heart’.

Katie had a passion for riding horses

Katie began suffering gynaecological pain in late June 2020, but after a visit to the GP was inconclusive, her mum took her to Warrington Hospital’s A&E department on June 30.

A scan revealed a large abscess, for which Katie was prescribed two courses of antibiotics. By July 7, the abscess failed to heal, and she appeared pale and exhausted, said Jeanette.

On July 14, at another emergency appointment because of ongoing intense pain, Katie was told she would need an operation the following day to drain the abscess.

A doctor decided against blood tests on the day and Katie was sent home. It was expected that Katie would undergo blood tests prior to her surgery the following day, however the surgery was cancelled.

Katie instead underwent an MRI scan and was given a follow-up appointment for August 18. She was advised to take co-codamol for the pain.

The inquest was told that if Katie had been given a blood test at this point, it would have shown that she was suffering from APML, a rare form of leukaemia, for which early treatment is vital.

On July 21, Katie attended her seventh interaction with Warrington Hospital asking for help with worsening symptoms.

Jeanette told the inquest how a consultant dismissed her concerns about Katie’s severe pain and fluctuating temperatures.

The mother felt her concerns about Katie’s worsening symptoms were not being taken seriously.

On July 26, Katie collapsed at home and was rushed to A&E at Warrington Hospital. Blood samples were finally taken and her leukaemia was diagnosed.

She was transferred to Alder Hey the following day and was placed in the high dependency unit.

A bone marrow biopsy to confirm the diagnosis was planned for July 29, and Jeanette was told that there was a cure rate for APML of 80 to 90 per cent.

Her family were told that there was a high risk of Katie suffering a bleed as her blood was not clotting properly, but that she would be treated with blood products.

This should have included a specialist blood-clotting medication called fibrinogen.

Warrington Hospital

Jeanette told the inquest that Katie was chatty and calling family and friends over the phone on the night of July 28.

However, despite Katie’s fibrinogen levels dropping to what the coroner heard were levels in the ‘danger zone’ from the early evening of July 28, Katie was not given fibrinogen.

The coroner heard that monitoring and treating fibrinogen levels were a basic and fundamental part of treatment for APML.

At 9am on July 19, Katie told her mum she had a headache. She was initially prescribed paracetamol and later morphine, but soon it became so severe that she cried with the pain, before collapsing.

A CT scan revealed Katie had suffered a catastrophic brain haemorrhage.

Alder Hey admitted that a new headache is a ‘red flag’ symptom of a bleed, and the coroner found that Alder Hey should have taken urgent action at this point., 

Katie underwent surgery and was placed on life-support, and when it became clear that Katie would not recover, she was taken off life-support two days later.

Katie died on July 31, with her mum Jeanette, dad Jonathan Wilkins, and sister Harriet Wilkins by her side.

The coroner said she would issue a Prevention of Future Deaths report to the Secretary of State for Health in relation to the fact that Katie’s APML, which is a haematological emergency, was managed primarily by the wrong speciality at Alder Hey.

Katie was managed during a critical period before her death by an oncologist with no expertise in this rare blood cancer, and a treatment plan set out by a haematologist was not followed.

Independent expert witness Dr Cathy Farrelly told the inquest that it was almost unheard of for an oncologist to manage this condition.

Dr Keenan, the trust haematologist at Alder Hey, said APML patients being managed by oncologists caused him concern and that he had raised these concerns to the trust after Katie died.

However, the coroner heard that due to national wide issues in recruiting haematologists, the trust ultimately decided to keep the same arrangements in place.

The family raised concerns that this would mean other children with APML could end up in the same situation as Katie, leading to further avoidable deaths.

Katie (right), with her sister Harriet

The coroner has recognised these concerns by raising this national issue directly with the Secretary of State for Health.

Following the conclusion of the inquest, Katie’s mum and dad said: “It is hard to believe that we have needlessly lost our funny, caring, sassy, loveable girl with a contagious smile.

“The loss of Katie has left a huge hole in our family and will forever be in our hearts. We will never forget her.

“On the day Katie was taken to Alder Hey and diagnosed with leukaemia, she asked her mum if she was going to die, and Jeanette told her: “No, you are in the best possible hands at Alder Hey”.

“We knew that Katie was at risk of a haemorrhage, but we put our trust in the specialist, world-class care of the Alder Hey medical staff.

“But the morning she was rushed to theatre due to a bleed on her brain was like something out of a horror film.

“It is still so hard to believe that our daughter was let down so catastrophically by the medical staff who we placed our complete trust in.

“Even after Katie had been let down so badly by Warrington Hospital, we believed that the staff at Alder Hey were experts who would treat our daughter with the utmost care.

“We thought that when we finally had a diagnosis, Katie would be okay as APML is so treatable and the survival rate is very high.

“However, we were wrong, and Katie was again let down by those who were responsible for her treatment.”

The family went on to say: “This inquest has exposed the full extent of the basic failings in Katie’s care by both Warrington and Alder Hey hospitals, and we are pleased that the care provided by both trusts has been recognised as neglect.

“The truth as to how she died and making sure that this never happens to another child has been a devasting journey for our family over the last two years, but it is what Katie deserves.

“We are relieved that the ongoing concerns we have about the level of care that current and future children with APML will receive due to a lack haematologists is being raised at a national level and will have to be addressed by the Secretary of State for Health.

“While nothing can bring Katie back, we are pleased that her legacy will be to protect other children with leukaemia.

Alder Hey Children’s Hospital (Image: Google Maps)

“We are grateful for the dedication of our legal team, and the professionalism of the expert witness and the coroner Ms Ainge.

“We sincerely hope that Warrington and Alder Hey hospitals act on the changes they have promised to make to improve the care for children with leukaemia.”

Julie Struthers, solicitor at Leigh Day which represented Katie’s parents, commented: “I am pleased that the coroner’s conclusions have recognised the full extent of the serious and fundamental failings in care that Katie received from both Warrington and Alder Hey hospitals.

“It has been hugely distressing for her family to hear that Katie’s death could have been prevented had she undergone a straightforward blood test earlier, or simply received the correct medication.

“I welcome the coroner’s decision to make a Prevention of Future Deaths report due to the ongoing concern that another child with a rare leukaemia such as Katie’s may not be looked after by the correct specialist, which could lead to further avoidable deaths.

“Through the inquest process, the strength and courage of Katie’s family has ensured that there has been proper scrutiny of her death.

“I join them in their hope that Warrington and Alder Hey put in place effective changes to ensure no other child’s life is lost due to such basic failings in care.”

In a statement, Dr Paul Fitzsimmons, executive medical director at Warrington Hospital, said: “We are deeply sorry for the loss of Katie and we send our sincere condolences to her family.

“Following Katie’s attendances at the trust in July 2020, the trust undertook a detailed investigation which identified a number of opportunities for learning.

“At that time and since, we have made changes to our policies and systems specifically relating to processes around early warning scores in children and young people, and earlier referrals to paediatric colleagues.

“We have also taken robust steps to mitigate against any potential delay in diagnosing any underlying oncological cancer conditions in the future.

“We fully accept the verdict of the coroner and will take forward any further recommendations once we receive the full narrative.

“We appreciate that nothing can bring Katie back and can only express once again how very sorry we are for her loss.”

A spokesman for Alder Hey Children’s NHS Foundation Trust statement added: “We wish to offer our deepest sympathy to the family of Katie.

Katie (right), with her sister Harriet

“The trust has thoroughly investigated the treatment provided in this case and highlighted that Katie did not receive the high standard of care we pride ourselves on delivering to our patients, and we apologise unreservedly to Katie’s family for this.

“The trust is fully committed to ensuring that lessons are learnt to improve care and to try and prevent such incidents occurring in the future.

“We have since introduced new measures to ensure events like this will not happen again, including new processes to ensure that robust lines of communication between haematology and oncology teams are in place.

“These changes will significantly strengthen our existing procedures and improve both patient safety and clinical and risk management throughout the organisation.”

Tributes from family and friends were paid to Katie on the first anniversary of her death, when she was described as a girl with a ‘big heart’ who ‘brought’ happiness into everyone lives.

Her sister Harriet said: “She was not only my little sister, but my best friend. She had a big heart and never failed to make me laugh.

“She was caring, supportive, and most of all the best sister I could have ever hoped for.”

Katie’s close friends described her as having a ‘beautiful personality’ which was ‘full of excitement’.

Bethany Hart, a close friend, explained: “Katie was always a joy to have around. She would always turn a frown into a smile and make you laugh, no matter what mood you were in.

“I will always miss our morning school run, where she would turn up to my house to pick me up with half brushed hair and untied shoelaces and yet was still confident we would make it on time.

“I will always miss her and forever remember the happiness she brought into all our lives.”

Ruby Smith, another close friend, commented: “Katie was my friend who constantly made me laugh, even in the most serious situations – her laugh was infectious.

“I will never forget the times she would text me asking if she should bring in sweets for us to eat in form time to keep us occupied, and times when we would laugh so hard we could not breathe, even though what we were laughing at probably was not even funny.

“Katie had such a beautiful personality full of excitement and confidence, and her absence leaves a hole in my life that could never ever be filled.”