20 Oct 2015

How neglect by an NHS hospital contributed to a teenager’s death

Karlysle Bryan was only 14 when he died last October from peritonitis – a burst appendix. When we went to see his family, their grief was still so unutterably raw.

Karlysle’s mother Lyndsey McKay said not a minute goes by where she doesn’t wish he was with her. Today the Waltham Forest coroner, Nadia Persaud, said Karlysle’s death was contributed to by neglect. Mrs Persaud said there was a gross failure to provide basic medical attention.

She said, had a full detailed assessment and observations been carried out, on balance of probability, he would have been referred to the surgical team before his appendix burst, and he would have survived.

After four days of vomiting and on the urgent advice of their GP, Karlysle’s father took him to Whipps Cross hospital in east London. It is part of Bart’s NHS Trust.

What happened in the next few hours can be best summed up as a long list of failings. A failure to properly record basic observations – heart rate, blood pressure and temperature. And to repeat them. There was a failure to further test an abnormal urine sample. And a failure to react to red flags – green vomit and soiling

The staff nurse wrote it all on a single sheet paper that has since disappeared. Notes couldn’t be found in the computer system. It wasn’t even clear if a reading of 131 was heart rate or blood pressure Either way they were warning signs.

The locum doctor did not order the observations to be retaken, she did not direct the nursing staff to carry out any further observations.

Karlysle was sent home with rehydration fluid. He collapsed in the early hours of the following morning. He was pronounced dead shortly after 9am on 21 October.


His mother told me that right up until the end, there in the hospital, she believed it would be all right. Now she says: “Even today I wish I had just grabbed him and picked him up and cuddled him while he was still with us. When I saw him lying there … If I could have just changed places with him.”

Today in court, Whipps Cross interim medical director turned to the family – 364 days after Karlysle died – and apologised for all the pain, hurt and suffering. The hospital later said they had made changes to ensure patients are discharged safely.

This is the second inquest in five days where a young person has died and the finding has been “contributed to by neglect”.

On Friday, it was into the death of Connor Sparrowhawk, an 18-year-old with autism and epilepsy. He drowned in the bath at an NHS short-term assessment centre. His observations had been cut from 10 minutes to one hour.

In both cases the NHS took too long to apologise. In both cases the families had to fight for information, there was a failure to communicate, there was a patent lack of compassion.

This follows the government’s commitment – post the Mid-Staffordshire hospital scandal – to be open and transparent.

They introduced a duty of candour. Over the past five days none of this has been evident.

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