Cambridge coroner calls for national guidelines after child's death during medical procedure
Cambridge's coroner is calling for urgent action to prevent more deaths, following an inquest into a six-year-old’s death at Addenbrooke's hospital
A coroner has called for national guidelines to be introduced after an inquest found that a six-year-old girl died from internal bleeding following a medical procedure at Addenbrooke’s Hospital.
Amelia Ridout underwent a bone marrow aspirate and trephine procedure on 16 June 2022. The procedure, conducted under general anaesthetic, was carried out by a paediatric oncology specialist. It was understood that a bilateral procedure was necessary due to the possibility of a solid cancer diagnosis. However, the senior clinical fellow who had ordered the procedure had not specified whether it should be unilateral or bilateral.
During the left-sided procedure, the doctor performing the operation noticed a spurt of blood upon removing the trephine needle. The supervising consultant haematologist was called in to assess the situation but found no immediate cause for concern. Shortly after, Amelia’s condition deteriorated, and she suffered cardiac arrest. The paediatric resuscitation team responded, and it was determined that she had sustained an internal bleed as a result of the procedure.
Emergency surgery was carried out in an attempt to stop the bleeding. Despite efforts by the surgical and resuscitation teams, Amelia was pronounced dead in the operating theatre. The inquest, which concluded on 21 March 2024, determined that the needle had accidentally pierced the iliac vessels, causing catastrophic internal bleeding.
Area Coroner for Cambridgeshire and Peterborough, Elizabeth Gray, has issued a report to the National Institute for Health and Care Excellence (NICE), the British Society for Haematology (BSH), and NHS England, raising concerns over the absence of national guidelines for performing the procedure.
“There is a risk that future deaths could occur unless action is taken,” she stated.
Gray has recommended the creation of national guidelines for the procedure, alongside a database to record cases and outcomes, ensuring oversight and improvements in safety measures. She has called for standardised methodology to be established, reducing the likelihood of similar incidents occurring in the future.
The organisations have until 8 April 2025 to respond with details of the actions they intend to take. If no action is planned, the coroner has the authority to escalate the issue further. The report has also been sent to Amelia’s family, Addenbrooke’s Hospital, and the Chief Coroner for England and Wales for further consideration.