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The death of a 15-year-old girl who went into cardiac arrest and died just hours after she was told she had an ear infection was caused by neglect, a coroner has ruled.
Herne Bay High School pupil Rosie Umney – a type 1 diabetic – was taken to the William Street Surgery on the evening of Monday, July 2, where she was checked by Dr Sadaf Mangi.
She had been displaying some of the symptoms of ketoacidosis – vomiting, hyperventilating and struggling to walk.
The doctor previously said that she initially believed Rosie could have had the illness after learning she was a type 1 diabetic.
But she thought otherwise after Georgina Umney said her daughter’s blood sugar readings had been normal that day.
Instead, the schoolgirl was diagnosed with an ear infection and prescribed antibiotics.
An ambulance was called to Rosie’s home in South Road that night after her mother was unable to wake her.
She was rushed to the QEQM hospital in Margate before 2.10am, where she later died.
A post-mortem later revealed her cause of death as diabetic ketoacidosis.
At an inquest into her death at Canterbury Coroner’s Court , assistant coroner James Dillon said Dr Mangi did not follow guidelines published by the National Institute for Health and Care Excellence (Nice).
They state a patient should be referred to hospital if they display symptoms such as shortness of breath, sickness and high temperatures.
The GP had previously conceded that she was unaware of guidance published by Nice.
Mr Dillon said: “Rosie Umney was admitted to hospital in the early hours of the morning on July 3 in an advanced state of diabetic ketacidosis.
“Her condition was not retrievable. The GP did not send her to hospital, but Nice guidelines would have led her to send Rosie there.
“The GP did not conduct checks of her blood sugar levels.”
Mr Dillon added that Dr Mangi had shown contrition, enrolled in refresher courses and had sent an apology to the Umneys.
When paramedic Richard Steinbeck arrived at Rosie’s home just before 1.10am, he was told by her parents that earlier tests had returned a normal reading of 7.9 millimoles per litre.
He drew two samples of Rosie’s blood from her earlobe and finger.
Her sugar levels were so high that his machine – and another he borrowed from a colleague – was unable to provide a reading.
The paramedic later used Rosie’s meter himself, which again returned safe readings of 7.8 and 8.6 millimoles per litre.
Two months before her death, batches of the test strips similar to the ones Rosie was using were recalled by their manufacturer Roche Diabetes Care because it was thought they could provide inaccurate readings.
"It’s said that there had been a recall of test strips, although there was no evidence that Rosie’s were affected..." Assistant coroner James Dillon
Also, none of the equipment was sent to Roche for it to carry out its own checks.
“It’s said that there had been a recall of test strips, although there was no evidence that Rosie’s were affected,” Mr Dillon added.
“They could not be tested because they had passed their expiry date. Two SECAmb (ambulabce service) meters were independently used and showed Rosie’s blood-sugar levels were extremely high.”
At the hearing it was noted by Mr Dillon that evidence did also suggest that Rosie’s machine had not been used for “some days”.
“Dr Mangi’s involvement cannot be seen in isolation,” he said.
“There is evidence [Rosie] was not compliant with the monitoring and treatment regime for her diabetes, including blood checks.
“These therefore led me to a finding of neglect.”
