Tragic Emmanuel Akinmuyiwa who died at Heartlands Hospital
A schoolboy died after staff at a Birmingham hospital "missed opportunities" to save his life, a coroner has ruled in a damning inquest.
Emmanuel Akinmuyiwa, seven, collapsed and died when he suffered a cardiac arrest during a blood transfusion at Heartlands Hospital.
The procedure was performed four days after the youngster, from Tyseley, was admitted on February 8, 2013.
Birmingham Coroner’s Court heard how Emmanuel would have survived had staff taken blood tests which would have shown a transfusion was required far sooner.
Tragic Emmanuel Akinmuyiwa with and his sister Christy
The schoolboy suffered from sickle cell disease, a hereditary disorder that can cause haemoglobin (red blood cells) to mutate and restrict blood flow.
The dangerous condition was raised by a GP who referred Emmanuel to Heartlands.
Dr Helen Goodyear, a consultant paediatrician, set up a five-point treatment plan in which she asked for his haemoglobin, or hb, levels to be monitored.
But her direct instructions were ignored by Heartlands staff, the inquest heard, and there was a "lack of urgency" before the transfusion was carried out -including a four-hour wait after it had finally been requested.
Emmanuel Akinmuyiwa with his mum Dupe Josephine, dad Moses and sister Christy
Dr Goodyear said she was "horrified" when she learned her treatment plan had been dismissed by a junior doctor without consultation.
Senior coroner Louise Hunt gave the cause of death as cardiac failure caused by severe anaemia due to sickle cell disease.
Mrs Hunt said: "In my conclusion I do find a gross failure in not doing the blood test on the tenth (of February) when there was a clear clinical need and a clear direction to do so.
"There were other failures - to provide a transfusion on either the eighth, ninth or tenth.. a failure by all staff to not recognise they had insufficient understanding of this condition and an appreciation of this very serious condition."
Mrs Hunt also ordered for a report to be sent to Clinical Commissioning Groups across the West Midlands and to NHS England to ensure all trusts were better placed to treat patients with sickle cell disease.
Emmanuel's father Oluwasemilogo wrote a letter of complaint to Heartlands and spoke of his loss in a written statement read out in court. "The whole experience was very traumatic for us,’" he said. "He was our youngest child and only son. We had been trying for another child since 1997 and had to wait until 2005. We moved to the UK in 2006 to give our children a better life.
"It's impossible for us to have another child now due to my wife's age. We are still struggling to come to terms with it and have constant recollections of his pain."
Emmanuel was admitted to hospital complaining of a fever, leg pains and dizziness.
His healthy hb 'base' level was 8.5 grams per deciliter of whole blood, but it dropped to 5.7 grams shortly after his admission and was just 2.7 grams when the transfusion was eventually performed.
Dr Sarah Wilson, a consultant haematologist at Birmingham Children's Hospital, which had been approached for advice on Emmanuel's treatment, said transfusions should be performed when a patient's hb count is more than two grams below their base level.
Dr Clive Ryder, who led an internal investigation into the case, told the court there were "missed opportunities" to manage Emmanuel's haemoglobin and that staff had "misjudged" the condition.