14/08/2014 12:48 BST | Updated 22/05/2015 06:12 BST

Girl, 5, Died Of Meningitis Hours After Being 'Let Down' By Two GPs

Girl, 5, died of meningitis hours after being 'let down' by two GPs

A five-year-old girl who died from meningitis had been seen by two GPs less than 48 hours before she died, an inquest heard.

The doctors thought Kelsey Smart was suffering from viral gastroenteritis but in fact she had the deadly brain condition.

The little girl was examined by an out-of-hours GP, then seen again the following morning by a doctor at her local surgery.

Three hours later she had a fit and was rushed to hospital where she later died, Avon coroner's court heard.

Her mother, Hannah Smart, said in a written statement she was concerned none of the doctors had considered meningitis.

A senior doctor at the local medical centre had later 'suggested that Kelsey had been let down by the doctors treating her', she said, adding: "These feelings are echoed by myself and my entire family."

Kelsey became poorly on 25 February last year, vomiting hourly throughout the night. She was tired and developed a small pinprick rash on her abdomen and upper left leg.

Her mother called Frendoc – an out-of-hours GP service in south Gloucestershire – and was told to give her Dioralyte, a brand of rehydration medicine, and ring back if she could not keep it down. When she was sick again, she took her daughter to see locum GP Jens Rohrbeck at Frenchay hospital, Bristol.

She told the inquest: "I showed Dr Rohrbeck the rash on Kelsey's chin, tummy, chest and leg and he simply pressed the rash with his finger and said it was caused by the virus Kelsey had.

"He explained he would send us down to the hospital to be seen but this would be a four-hour waste of time. He said it would be better for me to take Kelsey home and if she continued to be sick overnight I should take her to our family GP the next day."

The following morning she took Kelsey to The Orchard medical centre in Kingswood, where she was seen by Dr Sarah Grant. Smart said Kelsey had a temperature of 37.8C, was very agitated and pulled a clump of hair out of her head during the appointment.

She again highlighted Kelsey's rash. "Dr Grant prodded the rash with her finger and said it was linked to the virus."

She was told to bring Kelsey back at 4pm if there was no change. By lunchtime, fearing her daughter had appendicitis, she decided to drive her to hospital.

On the way, Kelsey had a fit, her mother pulled over and an ambulance was called.

Kelsey was admitted to Bristol Children's hospital and placed on life support but deteriorated.

After doctors informed her mother, a care assistant, and father Jamie, a painter and decorator, that she was brain dead, they took the decision to donate her organs.

Dr Rohrbeck told the inquest he had examined the rashes but felt they were 'very, very small and inconspicuous' and combined with other symptoms pointed to gastroenteritis.

"Personally I have never seen a case like this before," he told coroner Maria Voisin, and said with hindsight he would have sought further medical advice.

Dr Grant said: "I did think about meningitis as the cause of the rash but discounted that at the time, because the rash had not progressed and did not seem to be getting worse."

The inquest heard from two consultants at Bristol Children's hospital who said the disease had taken hold by the time Kelsey suffered her fit, and had she been admitted to hospital earlier it was unlikely doctors would have been able to reverse swelling to the brain.

Recording a narrative verdict, the coroner said: "It is clear from their evidence that earlier intervention is better but what cannot be said is whether earlier treatment would have resulted in a different outcome for Kelsey.

"Neither can we say exactly what would have happened if Kelsey had been admitted sooner."