Girl, seven, died of liver and heart failure three days after medics discharged her from hospital even though her lips were BLUE



Simran Dhesi was sent home despite her mother's concern, inquest hears



The schoolgirl was admitted to another hospital two days later

She died on the operating table as doctors tried to drain fluid from her heart

Doctor at Sandwell General Hospital told Simran's mother that her lips were blue because she was cold

Family said after the inquest they are considering taking legal action



A seven-year-old girl died from heart and liver failure three days after being discharged from an Accident and Emergency department with blue lips, an inquest heard.

Simran Dhesi was vomiting and complaining of abdominal pain when she was rushed to Sandwell General Hospital, West Midlands, the coroner was told.

But despite having blue lips - a sign of organ failure - Dr Raka Banerjee said the schoolgirl was 'fine' and sent her home.

Discharged: Simran Dhesi, seven, was released from the Accident and Emergency department at Sandwell General Hospital despite having blue lips, an inquest heard. She died three days later

She was rushed to another hospital two days later and died of cardiac failure on the operating table as doctors tried to drain fluid from her heart on September 10, 2010.

Simran's mother Tarlochan Dhesi, 34, told the inquest Dr Banerjee dismissed her concerns about her daughter's blue lips in the A&E department - and said she was cold.

In a statement read out at the inquest, she said: 'A lady doctor (at Sandwell General Hospital) checked Simran.

'She tested her urine, she took blood from Simran’s finger and she said Simran was okay.

'I asked the lady doctor to check Simran’s stomach. She moved her stomach this way and that way and said it was fine.

'I asked her why her stomach was so hard. She said it was fine. I asked about Simran’s lips being blue and she said it was because it was cold.'



Dr Banerjee was unable to attend the hearing because of a bad back but admitted in a statement that she had left Simran’s medical notes incomplete.



Her statement read: 'I know my notes are incomplete and the reason for this is I must have been interrupted.

'Unfortunately the A&E card must have filed before I could complete it. I’m sorry for this.

'I was certain I did not have concern for Simran’s well-being otherwise I would have not discharged her.

Released: The doctor at Sandwell General Hospital told Simran Dhesi's mother that her daughter's lips were blue because she was cold

'I would certainly have been aware if there had been an enlarged liver and I would have requested a paediatric opinion.'

The inquest heard Tarlochan, a care home worker, took Simran to her GP the day after she was discharged from Sandwell General Hospital when her condition worsened.

But the following day, on September 9, Simran’s condition had become so serious she was rushed to Birmingham City Hospital where doctors realised she had liver failure and fluid in her abdomen.

She was later transferred to Leicester Royal Infirmary where she underwent an emergency operation to drain the fluid from her heart and take the pressure off her liver. However, she went into cardiac arrest and was pronounced dead.



Dr James Greening, a paediatric consultant at Leicester Royal Infirmary, told the inquest doctors at Sandwell Hospital had failed to carry out the correct blood gas tests on Simran.

He said: 'With the benefit of hindsight if we had had the blood gas it would have helped us to know what was going on.'



Expert witness Dr Robert Sunderland, a consultant pediatrician at Birmingham Children’s Hospital, said there were 'warnings available' to the doctors from the tests done on Simran which would have flagged up her heart condition.

He said: 'With hindsight there was a warning there available because from the readings there was a possible problem with the liver which wasn’t identified.'

Death: Simran died after going into cardiac arrest at Leicester Royal Infirmary while undergoing emergency surgery

Returning a narrative verdict, Black Country Coroner Robin Balmain said: 'I have borne in mind these are natural causes but natural causes would not reflect this situation.

'Simran’s death was due to a rare complications in a congenital heart defect which had been corrected.

'The opportunity to treat and prevent the causes did not arise in time to prevent death.'

Simran’s parents Jatinder and Tarlochan said said they were considering taking legal action against the hospital she was discharged from.

In a statement they said: 'It has taken over three years for this inquest to take place.

'Even now, one of the key doctors who saw Simran first, did not give evidence, which was disappointing.

'Simran was a happy, playful little girl who had a beautiful smile bringing happiness to us and everyone in her life.

'She leaves a loving extended family whose lives have been shattered as a result of her tragic death and we can now only take comfort from happy memories of her short life.

'We believe the coroner’s inquiry has shown Simran was a very sick child who needed urgent specialist medical attention which sadly she never received.'

The family’s solicitor Rankeshwar Batta added: 'The tragedy of Simran’s death was, in our view, avoidable had appropriate and urgent steps been undertaken when she first attended hospital as her condition began to worsen in September 2010.

'This case was all about taking personal responsibility to diagnose a high risk condition and to ensure adequate treatment and a specialist referral was in place for a very sick child.