Table 3

Quotes to illustrate pathway to death

Non-compliance with treatment for chronic diseaseThe child’s father did not take her to either of the two outpatient appointments arranged when she lived with him in the month before her death. He also did not get her registered with a general practitioner until November 2015 (1 month before she died), even though she had lived with him since August 2015 and although both the college and the child’s community health team had contacted him on a number of occasions to remind him to do so. He did not return a number of calls from the paediatric diabetic nurse about how they were managing the child’s diabetes (case G).
Underlying disease process aloneThe child was admitted to hospital initially for assessment following his fall and for bruising which was noted on various parts of his body. Shortly after admission, it was identified that the child’s cardiac condition had deteriorated and …. he was admitted to critical care, a diagnosis of multiple organ failure was made. The child was transferred to the paediatric ward for end-of-life care (case H).
Not seeking medical advice for acute illnessThe child began to develop similar symptoms but did not recover and by late on Monday was displaying severe symptoms associated with prolonged vomiting. These were similar symptoms to those which had led to her previous hospital admission and mobile phone records show that mother was aware of this sending many texts to friends commenting that the child
was ‘as bad as last time’. During Monday night, there was further deterioration in her condition and on Tuesday morning she was unresponsive (case D).
Abuse and neglect leading to death… The cause of death was declared to be pneumonia with further causations being the chronic aspiration of gastric content. There was aspiration of food material in the airways with surrounding acute inflammations…These were identified as food from recent and old feeds suggesting possible abuse by force-feeding (case J).