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Christina Saleh
Christina, or Kristy as her family called her, was born in November 2003 in Greece, the youngest child of Saiel and Anna, she has two older sisters. She had a very happy childhood, in fact she had a very happy life, until the last couple weeks of it.
When Kristy was 6 her family moved to the UK where her father was completing his fellowship training as a doctor; he’s now a consultant paediatric nephrologist, but for two years the family lived in Birmingham and Manchester.
Kristy went to special schools in Birmingham and Manchester, because it was felt these would provide her with the best education, given her learning disabilities and autism.
Kristy thrived.
Kristy was almost entirely non-verbal, communicating instead through sounds, simple words, gestures and signs. She was also an expert in using emojis on her mobile phone to express how she was feeling, or to make her family members laugh. There was a lot of laughter.
Kristy’s first language was Greek, and although she knew a few English words and a few Arabic words, if anyone tried to communicate with her in English, a family member would translate into Greek so she could understand.
Kristy understood a lot more than most people assumed.
Kristy was an active child, she liked to move, and she liked to dance, especially to Michael Jackson songs. She had a great sense of humour and was a total foodie, her favourite dish was spaghetti.
After Saiel finished his fellowship training the family moved to Jordan. Kristy was eight years old by this point.
Six years later, as Kristy turned 14, she moved back to the UK with her mum and sisters. Saiel stayed behind to work. By now Kristy had also developed epilepsy.
Kristy’s family had had a good experience in the UK before and believed that she would get a good education; they also believed England had the best healthcare system in the world.
If only. The family moved to Kent.
Kristy’s family describe the process of placing her in school considerably more difficult in 2017 than it had been before. There were numerous assessments and hoops to jump through.
Eventually, three months before her death Kristy was offered a place at Milestone Academy.
Towards the end of July Kristy wasn’t feeling herself, her Mum and sister were concerned and she’d been constipated for almost a week.
On 31 July 2018 Kristy was taken to A&E at Darent Valley Hospital by ambulance. She was admitted onto a ward.
The family describe a living nightmare in the week that followed. Kristy was in hospital for 6 days but they felt that no-one appeared to be too bothered about understanding what was happening to her.
The staff had little or no awareness of learning disabilities or autism. The hospital notes from the day she was admitted state “A limited examination was carried out due to CS’s behaviour”.
The first of many, many statements of patient blaming and family blaming that follow in the hospital’s RCA investigation.
Kristy wasn’t eating or drinking normally, she was lethargic and stayed on her bed most of the time despite her family trying to coax her up and about.
Kristy had her mum or her sister with her at all times in hospital, they described how staff appeared more concerned for their welfare than Kristy’s.
By the 5th August Kristy had been in hospital for 5 days and hadn’t had her bowels open for 14 days. She was given an enema eventually, but her bowels still didn’t open fully. By Day 6 she still wasn’t eating or drinking normally, she was indicating she had discomfort in her tummy, but the hospital considered her medically fit for discharge.
Apparently the only reason Kristy hadn’t been discharged was because the hospital were waiting for a care package from social care to be put in place.
The family told me they felt the pressure was increasing on them to take Kristy home as she wasn’t being treated.
The hospital’s RCA notes that:
“It is documented that mum appeared angry talking about the plan to discharge CS from hospital whilst she was still constipated and showing aggression, with no food or fluid intake for a while”.
Despite the family’s concerns, they felt they had to agree to take Kristy home. She was discharged on the evening of 6 August.
On the morning of 8 August, Kristy collapsed at home. She was taken by ambulance to Kings College London where later that day she died.
Kristy was just 14. Her family have been fighting to try and get answers and some sort of accountability ever since.
Coroner found:
Christina known to have autism, global developmental delay and autism. Died at home on 8 August 2018 following a stay in hospital to address constipation and behaviour. First will deal with dehydration and whether Christina became dehydrated in hospital… reviews evidence heard, expected close observation because on 1-1 nursing, independent review considered charts reliable. LD specialist consistently recorded concerns about dehydration.
Dr Hasib considered she was sufficiently dehydrated on 1 August to require IV line but that never occurred. Doctors agreed if fluid charts were correct would be moderately dehydrated at discharge. Dr Ude confirmed was not enough but she was not aware dehydration was an issue so did not check charts… doctor concluded she was not significantly dehydrated and suggested other fluid intake than recorded… volumes of urine not charted after 3 August and she had a UTI.
Paucity of recording. Frequency of observations lower than PEWS score recommended…. on day of discharge no evidence hydration check, respiratory rate 25, heart rate risen to 100 from lower baseline…
No evidence discharge plan had laid out actions to ensure adequate hydration at home. Blood tests three hours following death suggested not dehydrated before death… Dr Marnerides said not easy to interpret, Prof Lucas said should not rely, conclude test was not reliable evidence…weight of evidence not adequately monitored for dehydration and was dehydrated during hospital stay but not sufficient evidence to conclude degree of dehydration at discharge.
Second matter whether prematurely discharged from hospital… court heard evidence constipation could be treated at home… no evidence that contradicts this, judgement as to when to discharge would seem to require professional judgement. Don’t consider degree of dehydration is necessarily bar to discharge unless required IV intervention at hospital and can not conclude that from the evidence.
There is a direct conflict of evidence as to whether Christina was too weak to walk as asserted by her sister, or was able as asserted by Dr Ude… I do not need to resolve this as it is not her degree of mobility at home, but in hospital, that is relevant to her death.
Coroner accepts Prof Lucas’ evidence that DVT formed during Christina’s hospital stay.
No-one finds acceptable the ultimatum of the social worker, but we’ve not heard from the social worker and I’ll not make a finding of fact either way.
Coroner accepts Anne Barrett’s evidence.
LD specialist service documented views about preference of treating constipation first… Discharge could not be said to be the family’s or specialist’s preference for Christina.
Although it was alleged discharge was necessary because of bed shortage, this was denied by the Trust representative and I make no findings on this.
There is no evidence if she hadn’t been discharged that she would have survived… medical attention might have been speedier but doesn’t amount to fact she would survive a pulmonary embolism in hospital.
Not evidence discharge decision per se is relevant matters to the conclusions I make.
I turn now to medical cause of death
1a Pulmonary Embolism
1b Deep Vein Thrombosis
Any doubt of DVT is assuaged by Prof Lucas’s evidence. Now consensus between pathologists and Dr Nelson of ambulance service that seizure causing collapse is secondary to cerebral hypoxia, secondary to pulmonary embolism, therefore it is not appropriate for epilepsy to feature on the medical certificate of death.
Differences about recording of global developmental delay on the death certificate… if a patient with diabetes with UTI partly treated, suffered limited mobility, certificate would not necessarily include diabetes, and if it did would be in 2.
No requirement if in doubt about contribution to death to record matters, and I note the family submission, and therefore I prefer Dr Marnerides submission and will not enter global developmental delay on the certificate.
Consensus immobility is significant cause of DVT… I accept the facts Christina was in hospital for nearly 6 days, accompanied to toilet frequently, left on one occasion to goto garden with family, otherwise stayed in cubicle, although was not bed bound. In adults would be regarded as immobility, difficulty make judgement in children as pulmonary embolism is so rare…. Prof Lucas did conclude immobility was underlying cause to DVT, accept that and will place it in 1c as reduced mobility.
Accept evidence of pharmacist that PE known to be side effect of Dianet… contributory matter in 2. Pathologists not able to opine on dehydration, but agreed if was found should be noted as contributory factor. Dehydration is not in the WELLS criteria and I accept it is not therefore a major risk factor, so should be included in 2 not 1c.
Christina had not opened her bowels for two weeks… Prof Lucas noted lack of changes in bowel at autopsy so insufficient evidence to conclude constipation was contributory cause to her pulmonary embolism, I accept his evidence. Turn now to resuscitation… no evidence to accept… allegations re diazepam not credible, accept Christina was in tonic phase of seizure caused by hypoxia as result of pulmonary embolism.
Fact the paramedics were unable to diagnose pulmonary embolism was not failure as not likely event in a child… accept arguments of paramedics that journey for under half hour any benefit of flying as opposed to going by road is marginal.
Neglect in coronial law requires all ingredients… submissions from family failure to diagnose and treat dehydration contributes to neglect… failure to provide nutrition or hydration to person in dependent position… more than minimally, negligibly or trivially contributed. I accept this failure is basic, narrow range of failures…. case supporting that is Nichols. Gross failure is more than simple error, wholly inadequate. Applying these not clear to me the failure can be described as gross, she was able to leave and was drinking, but in the event this is a misjudgement, I continue to consider other criteria… failure provide to a dependent person…. what dependent person’s condition appeared to be, original case of Jamieson.
Failure to follow routine procedures such as standard monitoring, omissions by different individuals can amount to picture of neglect. Seemed to me it was obvious for the family and LD staff hydration was a concern, communicated to the ward staff, monitoring inadequate so I conclude the need was, or should have been, obvious if doctors considered all issues and asked right questions an erroneous decision would not amount to neglect, but this was not situation here.
Direct causal connection… on balance of probabilities he or she would not have died when he did… it is wrong in law to conclude a matter was more than minimally contributed… that is not the test in neglect. Is no evidence, had she been fully hydrated, she would have survived and I accept dehydration is not a major risk factor… clearly not most severe end dehydration… no scientific evidence fully hydrating would have prevented, absence of that is fatal to neglect being recorded.
I therefore record:
1a Pulmonary embolism
1b Deep vein thrombosis
1c reduced mobility
2 oral contraception and dehydration
3 [Didn’t hear]
4 Natural causes contributed to by a degree of dehydration during a hospital stay
Family Statement
Christina was our beautiful daughter, a loving sister, and the heart of our family. There was never a quiet moment, and she was always singing and dancing. She understood what we said, no matter in Greek, Arabic, or English. We could understand what she wanted to say through her words and gestures. She loved going to her school, being outdoors and playing games. Christina was a healthy and happy child with learning disabilities and autism. Christina had so much to live for and was developing her life skills to live with dignity when she grew up.
On the 31st of July 2018, it had been nine days since Christina last had a bowel movement. She was in considerable pain and discomfort. Constipation had caused Christina anxiety and frustration, and she refused to eat and drink. We had asked for support from CAMHS a month earlier, on the 21st of June 2018. With no additional support at home and Christina’s deteriorating physical condition, Christina was admitted to A&E at Darent Valley Hospital via ambulance.
Christina was admitted to Willow ward on the 31st of July 2018 due to her constipation and the behaviour she was demonstrating due to pain. We were also concerned that she was dehydrated and was not eating. Surprisingly, doctors deemed Christina medically fit for discharge three days later, despite her constipation not being treated. As Christina’s family, we advocated hard for her to get the treatment she needed, as did a NELFT Learning Disability Team member, but the hospital staff did not listen. Christina received inadequate nutrition and hydration for the seven days she was an inpatient. It seemed to us they thought a child with disabilities could not have any physical problems. The hospital put the family under pressure to take her home. A Kent County Council social worker told us that she would need to be admitted to residential care if we didn’t take her home.
Eventually, we took Christina home late in the evening on the 6th of August 2018, without a care package of support because we felt we had no option. She was still dehydrated, constipated, not eating and very unwell, she couldn’t even walk from the ward to the car unaided. Two days later, Christina collapsed at home, and despite the efforts of the ambulance service and medical staff at Kings College Hospital, she died.
Christina’s death was entirely preventable. The evidence we’ve heard during this inquest clarifies that there is medical incompetency throughout Willow Ward at Darent Valley Hospital. It led to a lack of support and monitoring, miscommunication, an absence of leadership, and no one prepared to take overall responsibility for Christina’s care.
We want to thank HM Coroner Andrew Harris for his thorough investigation into Christina’s death. We are grateful that the failings in her care have finally been examined as part of the inquest process. The family would like to thank their legal team Maya Sikand at Doughty Street Chambers, Fiona McNelis at Taylor Rose, and Clare Evans, for their tireless work, compassion, and exceptional attention to detail. We also thank George Julian for live-tweeting the inquest and the transparency it brings to the process.