On 9th January 2013, this jurisdiction commenced an investigation into the death of Kirsty Childs, Age 20. The investigation concluded at the end of the inquest on 7th April 2016. The conclusion of the inquest was a narrative verdict:- Kirsty Louise Childs died at home septic shock caused by an undiagnosed and untreated mesenteric venous thrombosis. Kirsty her mother telephoned

Kirsty Childs was a 20 year old single parent who lived with her 2 year old daughter and parents in Denby Dale, Huddersfield. She had no significant medical history and was not on any prescribed medication. On Christmas 2012, she reported to her parents as not feeling well but with no specific symptoms_ On Sunday 3Oth December she began to experience severe abdominal pain, sickness and diarrhoea. Her mother contacted NHS Direct (the out of hours service operating at the time) at 20.35 hours on 31st December, because her daughters symptoms were Mary from and Kirsty Day worsening-This was the first of 18 phone calls made ad received by Kirsty and her family with NHS Direct; the Ambulance Service and the out of hours GP service, over the next 2 days in an attempt to obtain appropriate advice and care for Kirsty: The initial call was taken by a Health Adviser (as all initial and repeat calls were to the service): The Health Adviser (who not medically qualified) in undertaking an assessment selected the incorrect computer generated questionnaire, which resulted in the call being given lower priority for a call back by a Nurse Adviser. Kirsty's mother phoned the service again at 1.09 hours, now Ist January, as no call back had been received_ The Health Adviser did not appear to undertake a review of the record made of the initial telephone call (something which appeared to be the case on phone call to the service) but proceeded to undertake new assessment: Kirsty's mother was advised that a Nurse Adviser would call back within 1 hour. In fact, a call was received by a Nurse Adviser within half an hour. Kirsty was asked to detail her symptoms which she did, and added that she had noticed blood in her bowel motion and describes her bowel motion as really dark brown: The Nurse Adviser also worked through pre-determined computer generated questionnaire, selected after hearing the patient's symptoms and identifying the most serious The Nurse Adviser concluded that Kirsty was suffering from and she should self -care, and advised that if her symptoms worsened, she should phone the service back: heard evidence from an independent Vascular Surgeon that the Nurse Adviser should have asked more questions surrounding the presence of blood in Kirsty's bowel motion. He indicated that if these questions had been asked it should have become clear that Kirsty was not suffering from a gastrointestinal bug, and that arrangements should have been made for Kirsty to be reviewed by a Doctor, either assessed at home by the emergency out of hours General Practitioners service, Or, referred to her local Accident and Emergency Service. He confirmed that if this had happened, it is likely that Kirsty would have been admitted to hospital, undergone investigations and diagnosed with her actual condition, a superior mesenteric venous thrombosis, which he considered at this stage was treatable and it is likely Kirsty would have survived Kirsty herself contacted

In my opinion action should be taken to prevent future deaths and believe you [ANDIOR your organisation] have the power to take such action.