NORTH Hampshire hospital doctors have been accused of Gross negligence by coroners investigating the tragic death of 11-year-old Alton schoolgirl Charlotte Pomerance. A coroner gave the damning indictment on Tuesday at the conclusion of a two-day inquest into the death of the 11-year-old. And an independent report into the tragedy revealed that the medics' failures to communicate with each other exposed a wider problem in the "new NHS", where doctors' working hours were reduced. The report also found that a simple X-ray could have prevented the tragedy from happening. It also questioned why no action was taken even when the youngster was expelling green coloured vomit and nurses failed to inform doctors that Charlotte had to be carried into a hospital on her second visit, because she was too ill to walk. The Amery Hill School girl collapsed and died from a major bowel obstruction after doctors misdiagnosed it as the winter vomiting bug. Despite being taken to hospital by her parents twice in three days, Charlotte was sent home after doctors said she was just another victim of the bug which beset Britain last February. Medical experts told the inquest that Charlotte's death could have been prevented. They admitted a catalogue of errors and miscommunication by medical staff at the North Hampshire Hospital in Basingstoke, contributed to a failure to diagnose Charlotte's illness. On Tuesday, Coroner Andrew Bradley told the inquest that he found the hospital practices had been grossly negligent. These included a combination of the decisions being taken and the lack of guidance given to Charlotte's family. He added that a simple X-ray might have resolved Charlotte's problem. "All the experts agreed that the presence of green vomit was a significant factor which demanded explanation," he added. The inquest was told that doctors at the North Hampshire Hospital failed to exchange notes and records of Charlotte's patient history during handovers. This would have indicated something more serious than a viral bug, the coroner was told. When doctors sent Charlotte back to her home in Alton for the second time they failed to tell her devastated parents, Alison and Michael, to look for warning signs of a more serious illness. Consultant paediatrician David Robinson, who compiled an independent report into Charlotte's death, said the case exemplified a wider problem in the "new" NHS, saying: "It feels like they (the doctors) are working in isolation and not as a team. "If they had been working together, they would have said 'let's go and get some blood tests, X-rays, or a surgeon'." Dr Robinson, of Queen's Hospital, Romford, Essex, added: "Failure to communicate in the new NHS, with doctors' hours reducing, is an issue of wider importance." He explained that doctors were expected to exchange printouts on patients at staff handover, but the trend appeared to suggest they did not. In Charlotte's case doctors did not exchange telephone notes and medical notes which actually showed her five day history of "intermittent" spells of violent vomiting, the inquest in Basingstoke was told. Nurses failed to tell doctors she had been carried in and out of the hospital because she could not walk on her second visit. The coroner was told that medical experts later agreed this information was "significant" and, if they had been told, would have led to Charlotte being detained in hospital under observation. Michael and Alison Pomerance both told the inquest that doctors did not listen to what they were telling them about Charlotte's symptoms when they took her to hospital. Mr Pomerance, himself a qualified paramedic trained in America, told doctors he suspected his daughter did not have the winter vomiting bug. He said that she had not had any diarrhoea and no one else in the family had contracted the gastro-enteritis bug. The coroner was also told that in a phone call to the hospital, Dr Lisa Moore-Ramdin, a trainee specialist paediatric registrar, reassured Mr Pomerance that his daughter vomiting green bile and blood was common with symptoms of the sickness bug and that she "would get better." When he replied that she had already been sick for four days and asked how long her illness would continue, the doctor replied: "How long is a piece of string?" Dr Robinson told the inquest: "If you see a child doubling up in pain and vomiting green bile, that necessitates blood tests and X-rays." The coroner had been told that on the evening of Wednesday, February 8 last year, Charlotte's condition had deteriorated (alarmingly) at her home. They rang 999 and Charlotte was rushed back to hospital but suffered a cardiac arrest en- route. After 98 minutes of attempting to revive her, doctors pronounced her dead on February 9. A post-mortem examination showed she had died from a combination of peritonitis, perforation of the small intestine and malrotation of the colon. Doctors told Mr Pomerance that the diagnosis "was there to be had" and "the system had failed him". Recording his verdict Mr Bradley said: "Charlotte Pomerance was admitted to North Hampshire Hospital on February 4, suffering from an abdominal pain. "She suffered vomiting and was readmitted, but the pain was not detected. She was admitted on February 9 2006, having suffered respiratory arrest and she died. "She suffered a perforated bowel which had caused her death." After the verdict was read out, Mrs Pomerance collapsed in floods of tears into the arms of her husband. They were too distraught to talk after the hearing. However, family lawyer Alison McClure said: "They are deeply distressed at having heard that their daughter's death was entirely preventable and was contributed to by the negligence of those doctors charged with her care." After the verdict, a spokesman for Basingstoke and North Hampshire NHS Foundation Trust said: "The trust extends its deepest sympathies to Mr and Mrs Pomerance and their family for the tragic events leading to the death of their daughter Charlotte on February 9, 2006. "The Coroner carefully considered all the evidence before him and came to the conclusion that Charlotte died from natural causes due to an obstruction of the bowel. "The Coroner was concerned that a correct diagnosis had not been made and this was a preventable death. "Charlotte had been seen at the hospital in the days prior to her death and her parents had also been in telephone contact. "The trust accepts the comments made by the Coroner and following Charlotte's death it critically reviewed its procedures. "Prior to Tuesday's verdict it had already put in place further procedures to reinforce its existing protocols designed to ensure continuity of patient care and accurate recording of clinical contacts. "The trust will continue to review its processes in light of the Coroner's comments today." l Fellow pupils at Amery Hill School in Alton set up their own memorial to Charlotte. According to head teacher, Stephen Crabtree, the former Year 7 youngsters, and in particular Charlotte's tutor group, have put up a bird table and have undertaken to feed the birds as a way of remembering their friend. They have also erected a plaque in memory of the popular pupil.
