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Full Report
 | November 25, 1992 |
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A distraught mother was kept on 'hold' by a recorded message when she called an ambulance as her tiny daughter lay dead or dying, an inquest was told today Wednesday. The hearing at Southwark Coroners Court was told of under-staffing at the London Ambulance Service and of doctors misdiagnosing her two-year-old daughter's mysterious illness as pneumonia. During the three hour inquest the young mother thumped her chest in grief and cried before collecting herself with dignity to ask searching questions of doctors. More than a dozen members of her family steadied her as she left the court after coroner Sir Montague Levine recorded a verdict of death by natural causes. The inquest was told that bubbly Levern Binnom, born healthy in Lambeth on September 19, 1990, fell ill on October 6 this year and died the next day. Mother Mrs Angela Duhaney, of 1 Calidore Close, Endymion Road, Brixton, said: 'I woke her up at about 3pm and noticed that she was breathing wrong. The breath seemed stuck inside her. She was gasping.' She added: 'There was blood in her mouth and nose and her eyes were flickering. It was like she was having a turn - like you see on telly when someone is going to die.' The young mother, who lives alone, ran into the street alerting two nearby workmen who telephoned for an ambulance. Doctors at Kings College Hospital told her that the child had a chest infection and she stayed by the toddler's bedside all night. The next day her daughter was running around the ward playing with other children. Duty doctor Dr Peter Mackay diagnosed pneumonia but said she was on the mend and discharged her. 'I took my daughter home and put her to bed and just watched her because I was just glad to have her back,' the tearful mother told the inquest. But at 7.15pm that night Miss Duhaney tried in vain to wake her daughter. 'I slapped her but she was just floppy. Then I ran to a telephone box to dial 999,' she said. The coroner - a former GP - shook his head in apparent disbelief as he heard how the mother was put on to an ambulance call 'stacking' system with a recorded message for 115 seconds with no human contact - then she fled in panic to get help elsewhere. Sir Montague said: 'I hope this system of stacking with a recorded message has been stopped. I think it is terribly, terribly wrong to have an inhuman message while someone waits in distress. 'Stacking is caused by a people problem, not computers and the London Ambulance Service did not have enough staff.' Ambulance control room manager Russell Mansford confirmed that staff had been increased since that incident and subsequent adverse publicity in the national press over other incidents. He said the stacking message system had since been changed. The pretty young mother, continuing with her story, said she took the the toddler to Brixton Police Station. There a visiting doctor tried to resuscitate the child in a waiting room, but found no obvious signs of life. Little Levern was then rushed to Kings College Hospital by ambulance but was pronounced dead on arrival. During the inquest, Mrs Duhaney demanded to know why pneumonia was originally diagnosed when the pathologist had found there was nothing wrong with the child's lungs. But pathologist Dr David Rouse said the symptoms would have looked similar to pneumonia. In evidence, directing his remarks to the mother, he said: 'Looking at your child's heart in my hand, it was about the size of a tangerine. It looked perfectly normal and it was only under the microscope that I noticed that some of the heart fibres were inflamed. 'Some doctors would say that there was nothing abnormal in this inflammation and that many people live with this condition in their daily lives. 'It would be impossible for doctors to diagnose this condition and even if they could have, there would have been nothing they could do. This child would have died whether in hospital or not. It is a very, very rare condition in a child. 'We have seen this before with children who have seemed well and they have simply died in the arms of doctors.' Summing up, Sir Montague said: 'This was a normal child who had only suffered from colds and an ear infection. Doctors had undertaken many tests on the child. Who was to know that a very rare condition, similar in symptoms to pneumonia, was at work? 'Sadly and dramatically, when the mother found the child she was dead.' After the hearing Dr Rouse said that hundreds of recorded cases of cot death could probably be attributed to the same heart fibre inflamation that Levern suffered, which led to her heart stopping. Dr Rouse added that in many areas of England inquests were not held in cases of suspected cot death, and simply recorded as death by natural causes. ENDS LLLL | |