On 24th May 2016 commenced an investigation into the death of Isabel Lily GENTRY Aged 16_ The investigation concluded at the end of the inquest on 17in March 2017. The conclusion of the inquest was that the medical cause of death should be recorded la) Group B meningococcal meningitis Box 3 read as follows: Isabel Gentry had meningitis, she became IIl on 17th 2016 her 'symptoms included: headache all but worse in the evening; neck pain; a fever; shivering; vomiting, muscular pain, dizziness and she had fainted once; she had loose stools for 3 days. The paramedic that examined her considered that she may have sepsis as part of his differential diagnosis. Isabel was taken to hospital. The doctor did not take an accurate history or a full history and did not reach a differential diagnosis which should have included sepsis and SIRS. The observations and the bloods taken were not normal: The diagnosis of viral gastroenteritis was not accurate: The vital signs were not considered in the light of the fluid and medication she had received. The previous case of meningitis was not acted upon: There was no senior review. Isabel was discharged on the morning of 18th May. During that she became more unwell Isabel was taken back to the Bristol Royal Infirmary that evening was treated but her condition deteriorated and she died on 2Oth May 2016_ Way May day day

The conclusion as to the death based on all the evidence was recorded as Natural causes contributed to by neglect

The circumstances were recorded in Box 3 which are reflected above. In summary Isabel Gentry became ill with meningitis on 17lh 2016. She attended the Bristol Royal Infirmary and was discharged on 18"h May with a diagnosis of viral gastroenteritis _ As the she became more unwell and was readmitted to the Bristol Royal Infirmary on 'rogresedhatebeningeThordiagnoellsaod meningadmiteconfire Bdistd Rogay despite appropriate care and treatment her condition deteriorated and she died on 20" May 2016_

In my opinion action should be taken to prevent future deaths and believe you have the power to take such action

Isabel Gentry had meningitis, she became IIl on 17th 2016 her 'symptoms included: headache all but worse in the evening; neck pain; a fever; shivering; vomiting, muscular pain, dizziness and she had fainted once; she had loose stools for 3 days. The paramedic that examined her considered that she may have sepsis as part of his differential diagnosis. Isabel was taken to hospital. The doctor did not take an accurate history or a full history and did not reach a differential diagnosis which should have included sepsis and SIRS. The observations and the bloods taken were not normal: The diagnosis of viral gastroenteritis was not accurate: The vital signs were not considered in the light of the fluid and medication she had received. The previous case of meningitis was not acted upon: There was no senior review. Isabel was discharged on the morning of 18th May. During that she became more unwell Isabel was taken back to the Bristol Royal Infirmary that evening was treated but her condition deteriorated and she died on 2Oth May 2016_ Way May day day

The conclusion as to the death based on all the evidence was recorded as Natural causes contributed to by neglect