The family of a sports mad 10-year-old who died after NHS staff failed to spot a brain injury have spoken of their ‘pain and torture’.
Gianni Khan, of Williton Way, Luton, died on December 28– a week after getting a knock to the head when coming off a bouncy castle at a friend’s birthday party.
When picked up with his two brothers by mother Maria, Gianni complained of a headache and later threw up the Calpol given to him.
The Hillborough Junior School pupil was taken to Luton & Dunstable Hospital, where he was streamed away from Accident & Emergency to the on-site Urgent GP Clinic.
Despite vomiting again Maria was advised to take Gianni home, where his condition continued to deteriorate.
The next morning paramedics were called at 7.30am, but after being assessed he was not taken back to hospital.
The following evening Maria took her son to his local GP at Churchfield Medical Centre, Crawley Green Road, where he collapsed and went into a coma.
Back at the L&D a scan showed Gianni had sustained a double fracture in the incident two days previously, which had caused massive internal bleeding.
He was taken to Addenbrooke’s Hospital for emergency surgery but declared brain dead on December 28.
Following Gianni’s death the L&D launched a serious incident investigation to look at the series of events which saw the child sent to the GP Clinic and to determine whether there are any errors in its protocol for children with head injuries.
It concluded that care “met required standards” but issued recommendations that the streaming system and processes for head injuries are reviewed.
The report also stated that the Trust should “consider and review” guidance from National Institute for Health and Care Excellence (NICE) on head injuries.
During the inquest, which concluded on Monday, it was revealed that the Luton Athletic club runner would have been referred for further treatment at the Urgent GP Clinic if he had vomited three times, even though NICE guidelines suggest a CT scan should be carried out after “more than one episode of vomiting”.
Gianni had thrown up twice prior to his discharge home on December 21.
When asked about NICE guidelines Dr Ramesh Soma, who assessed Gianni at the clinic, admitted: “They should be followed”.
The boy’s family have described their disbelief at the treatment he received.
Gianni’s uncle David Parocki said: “The investigation report is a whitewash. It is clear to us that the hospital and GP service are still dancing on a pin to say that the correct guidelines were followed.
“It continues to extend the pain and torture the family are going through to see the way the hospital and GP service continue their denial of any wrongdoing.
“There is not an acceptance that procedures are completely at odds with NiCE guidelines. They have got to wake up.”
Mr Parocki added his frustration that the nurse who streamed Gianni to the clinic was not available for the inquest despite a request for attendance from coroner Tom Osborne.
He said: “We met with members of the L&D board and we were given assurances that the nurse would be made available, now we hear she is on leave.
“It would have been far simpler if the hospital put the witnesses up and admit they got it wrong. Gianni should have been assessed in the emergency department.”
Despite the investigation report concluding Gianni’s care “met required standards” it was revealed at the inquest that the hospital has changed its streaming process for children with head injuries.
A hospital spokesperson said this week: “The L&D can confirm that since this tragic incident Luton Clinical Commissioning Group have agreed that all paediatric and adult head injury cases who arrive at the L&D are now triaged and treated by hospital staff in the Accident and Emergency Department and will not be streamed to Local Healthcare Solutions.”
During its own investigation the East of England Ambulance Service NHS Trust admitted failings with care Gianni received from paramedics.
An EEAST spokesperson said: “We apologise to the family and have put in place an action plan following the investigation, which was acknowledged by the coroner. This has included providing support and training to the member of staff involved. In addition the Trust is putting in place a range of actions to improve services to patients across the board, including recruiting hundreds of student paramedics and increasing the number of ambulances on the road.”
Following the inquest coroner Tom Osborn confirmed that he would prepare a Schedule 5 report for the Chief Coroner, to make suggestions to prevent future deaths like Gianni’s.
Mr Osborn told his family: “If there is the smallest consolation for you it would be that as a result of this changes may be made to prevent future circumstances of Gianni’s death.”
Gianni was a talented middle-distance runner who had won the Luton Primary Schools’ Cross Country Championship two months before his death. Hundreds turned out to a charity run in his honour in January, held at Luton Athletic Club.
Mr Parocki said: “This is a personal tragedy for Gianni’s mother, father and two brothers, Antonio and Enrique. He was a beloved son, devoted brother, nephew and best friend to many.”