A young girl who was suffering from a 'tummy bug' tragically died after doctor sent her home before she deteriorated and passed away as her family raced back to hospital.
Esma Guzel was just five-years-old when she suddenly became unwell and her family rushed her to hospital in the early hours of May 10, 2019.
The child had suffered from a cardiac arrest but after a post-mortem it was revealed that the schoolgirl had a rare health condition which had not yet been diagnosed.
Esma suffered from Congenital Diaphragmatic Hernia (CDH), a condition which cannot be detected in pre-natal ultrasounds and was also undiagnosed by the child's GP the night before her tragic death.
On Tuesday at Hull Coroners' Court during the inquest into Esma's heartbreaking death it was revealed from health experts that her cardiac arrest was caused by the CDH and part of her bowel becoming lodged in the hole in her diaphragm.
Esma’s mum previously spoke to Hull Live in the immediate months after Esma’s tragic death to help raise awareness of CDH.
At the time, she said that the “spark of life she made has gone” and Esma loved swimming and gymnastics.
She said of the immediate signs when Esma fell unwell: “She came home from school and was normal, went to my mum’s for her tea and just said, ‘Nanna, I feel sick’ and she was sick at my mum’s house.”
The family made an appointment to see a GP on the evening of May 9, where an assessment made of Esma concluded the cause was likely a tummy bug, but advice was given to contact NHS 111 if the ill health continued.
Esma’s mum then called 111 at 1.38am on May 10 and was advised to take her to an out-of-hours GP service in Beverley.
Tragically, by the time Esma and her dad reached there, she had died. A doctor carried out CPR and Esma was taken to Hull Royal Infirmary, but it was too late.
The bulk of Monday’s proceedings at Hull Coroners’ Court was taken up by the testimonies and questions for two independent experts.
David Crabbe, a consultant paediatric surgeon, explained that CDH is a condition which affects approximately 1 in 2,500 births and usually can be detected in ultrasound scans.
Esma had a Bochdalek CDH, consistent with a late presenting condition and radiology evidence indicated that it was simply not possible to have identified it on the three pre-natal scans.
If ever diagnosed, Esma would have been prepared for surgery and the outlook for late presenting CDH after surgery is excellent.
The hole in the diaphragm was small, which led to the incarceration of the illeum part of the bowel in the hernia before she died, consistent with the symptoms Esma was reported as having, namely abdominal pain and vomiting.
The progressive intertestinal obstruction and hypovolemic shock, fluid loss in the body, led to the fatal cardiac arrest.
Mr Crabbe made clear that the GP’s assessment of May 9 could not have foreseen the cardiac arrest and he could not identify a specific trigger for the bowel’s sudden incarceration.
He also stated that had Esma’s cardiac arrest occurred in hospital, it was likely on the balance of probabilities that she would have survived.
The highest level response that the 111 call at 1.38am could have prompted was a Category 3 dispatch of an ambulance within an average 120 minutes, but Esma died shortly after 2.20am.
Dr Lynette Hykin provided an independent assessment of the GP’s interaction with Esma on May 9.
Esma had been in good health, except for an GP-directed emergency admission in January 2019 to hospital after a diagnosed chest infection. On May 9, shortly after 5pm, she presented with abdominal pains and had been vomiting.
The GP noted Esma was miserable but chatty and as part of her assessment, carried out an abdominal examination.
Esma’s mum and the GP had different recollections as to Esma’s body position when examined abdominally, with the GP recalling examining her flat on her back before she curled up onto her side.
Dr Hykin said there were no GP assessment features that dictated hospital referral. She expressed potential concerns of care falling below the standard of a reasonably competent GP with regard to assessment of the abdominal pain Esma suffered and the colour of the vomit, which worsened by the time of the 111 overnight call to dark brown from light.
However, those concerns about the GP assessment fell away if the GP’s recollections of it were found to be correct.
Assistant coroner Dr Dominic Bell expressed his gratitude to the Esma’s parents, in court throughout the day’s proceedings: “Once again, I thank you for your dignified conduct.” He indicated that the inquest would resume on Wednesday afternoon with a conclusion expected.
“We are only moving towards the conclusion of the first part,” he added, in a reference to separate Section 28 regulation proceedings concerning a report to prevent future deaths, set to take place in April.
CDH UK is a charity dedicated to raising awareness of and supporting those affected by Congenital Diaphragmatic Hernia.
To find out more about the condition, visit their website here.
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