A teenage boy would have survived a brain haemorrhage if doctors had not made a series of failures in diagnosis and treatment, a coroner ruled today.
Lee Nicholls, 16, died after an aneurysm on his brain exploded two weeks after he was taken into hospital suffering from severe headaches, vomiting and double vision.
Lee, from Nailsea, in North Somerset, collapsed in November 2004 after suffering a brain haemorrhage caused by a rare and difficult to reach aneurysm.
Surgeons operated using a non-invasive coil method but over the next few months Lee had difficulty walking and had mood changes.
At the end of February 2005 Lee was rushed to Weston General Hospital where he was wrongly diagnosed with meningitis and given anti-biotics.
Today coroner Brian Whitehouse said doctors massively underestimated Lee's condition and failed to transfer him to a specialist neurosurgery unit at Frenchay Hospital in Bristol.
A lumber puncture was performed on Lee which should have been tested for a yellow fluid which would suggest bleeding on the brain but this was never done, which Mr Whitehouse said was a "dismal failure".
A few weeks after being discharged from hospital Lee collapsed and was put on a life support machine at Frenchay Hospital but died on March 29 2005.
He had suffered another haemorrhage caused by the original aneurysm continuing to grow but this had been missed on two CT scans.
Expert neurosurgeons who gave evidence at the inquest in Flax Bourton, Somerset, last month said he should have been given an angiogram at Frenchay to identify the aneurysm which could have been operated on.
However the angiogram could not be carried out because it was Easter bank holiday and the hospital did not routinely perform angiograms on weekends or bank holidays.
The inquest resumed today for Mr Whitehouse to give his full ruling and he gave a verdict that Lee died of natural causes but neglect by both hospitals contributed to his death.
"The combination of errors and commissions including the failure to transfer Lee, the underestimation of his condition and the failure to carry out the right tests significantly contributed to Lee's death," he said.
"If it had not been for these failures Lee would have survived or at least his life would have been prolonged.
"I find it difficult to be complacent about the lack of action over the Easter weekend.
"I am conscious of the hard work of the medical staff at all hospitals but when Lee was at Weston hospital there was a serious underestimation of his condition."
In a statement Lee's mother Kate Nicholls said: "Losing Lee has had a devastating effect on our family, to be told his death could have been prevented is completely soul destroying.
"We put our trust in the hospital staff, yet they did nothing.
"Emergency medical intervention needs to be available 24/7 in order to save lives.
"My family have lost their faith in the NHS and we hope changes can be made to ensure that in the future people can feel safe whenever they are in need of medical attention."Reuse content