20th July 2021 – Before North East Kent Area Coroner Joanne Andrews
12th July – 20th July 2021
Luchii Gavrilescu, a 5 week old baby died after three A&E attendances at QEQM, Margate on 6 th December 2019. A jury inquest has heard a number of criticisms of the care he received over this period of time.The family were represented pro-bono (there being no funding for representation) by counsel, James Robottom of 7BR and our solicitor, Francesca Beach.
The facts recounted to the jury were that Luchii presented to QEQM with his mother on 29 November 2019. Luchii was suffering with a mottled rash, a snuffly nose, erratic breathing and reduced feeding. He was seen by two junior doctors in the A&E department, diagnosed with bronchiolitis and sent home without further investigation or treatment despite the first doctor recognising that further investigation was necessary.
On 3 rd December 2019 his mother re-presented to QEQM with Luchii after being referred by her GP. Luchii had erratic breathing with increased work, reduced feeding and a chesty cough. The GP considered he had the clinical signs of a chest infection and sent him to Hospital to be seen by a paediatric doctor. Luchii was instead seen by an advanced nurse practitioner who considered his observations to be normal and sent him home with a diagnosis of resolving bronchiolitis after approximately three hours in the department.
Luchii’s final presentation was on 6 th December 2019 when he was taken to QEQM via ambulance with erratic breathing, apnoea and a period of floppiness. There then followed a delay in the recognition of the seriousness of Luchii’s condition and escalation to a more senior doctor at an earlier stage due to:-
failures at handover; a failure of senior paediatric medical staff to attend the A&E department;
and an unsafe transfer between ward and theatre without a stable airway.
Sadly, after multiple resuscitation attempts Luchii passed away that day.
A post mortem was carried out which determined Luchii’s cause of death to be disseminated tuberculosis infection and lymphocytic myocarditis.
Following this revelation Luchii’s father, Vlado Gavrilescu, was himself diagnosed with TB. A review of a chest x-ray taken of Vlado at William Harvey Hospital in March 2018 demonstrated signs of TB, and the East Kent Trust have now admitted that Vlado should have been diagnosed and treated for his TB at that point.
At that time, Vlado was in the early stages of active TB and the Trust accepted at inquest that, on the balance of probabilities, Vlado’s TB was sadly the cause of Luchii’s TB. The Trust also accepted that, on the balance of probabilities, had Vlado’s TB had been identified and treated in 2018, then Luchii would not have contracted TB and his death would not have occurred.
Professor Habibi, the Coroner’s expert, found that at no point did Luchii’s presentation on the 29th or the 3rd fit the clinical signs of bronchiolitis and had he undergone senior clinical review by a paediatric registrar or consultant, as he should have, he would have been admitted and undergone investigations as to the cause of his worsening symptoms. Professor Habibi could not say that on the balance of probabilities Luchii would not have died but for the failure to admit and treat him on those dates.
At inquest the Trust sought to demonstrate that they had learned from Luchii’s sad death and have made substantial changes to their paediatric practice producing 59 action points including:-
stressing to staff the importance of senior paediatric review both in light of clinical deterioration and before the discharge of a baby;
ensuring sufficient staffing of the paediatric team; and changes in how handovers between paediatric medical staff take place.
After 6 days of evidence, on 20th July 2021, the inquest into Luchii’s death concluded that Luchii died due to natural causes as part of the natural progression of TB. They noted in the record of inquest that it was likely that it was Vlado’s TB, which was undiagnosed, that was passed to Luchii and culminated in his passing.
Laura Cooke, mother of Luchii Gavrilescu said: ‘’I am so grateful to James and Francesca for being by my side this week and for helping me navigate this complicated and heart wrenching process. Although I am glad the Trust have made admissions regarding both Luchii and Vlado’s care it will never bring my little boy back and that is something Vlado and I will have to live with for the rest of our lives.’’
Francesca Beach of Fairweathers Solicitors who represent the family, said: ‘’This past week has been a truly difficult experience for the family having to relieve these painful memories however it has also been extremely important for them to hear from the medical staff that were involved in their son’s care and also have their fears regarding that care confirmed by a Coronial expert. Given that the Trust admitted liability in the civil case so early on there was a risk that they would not get the most out of the inquest due to lack of representation however counsel, James Robottom of 7BR, kindly agreed to appear pro-bono alongside me and that has been invaluable in securing the answers to the outstanding questions the family had. ‘’
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