Re: Tanisha Narraway

One-week inquest into the death of a 13-year old girl who had a history of a worsening cough and weight loss. She was deemed not acutely unwell and was to be seen the following week. She was examined with nowhere to lie flat. A chest x-ray showed mediastinal mass, but was not identified upon review. She was discharged, but re-attended the next day. A tumour and fluid around her heart had progressed, surgery was unsuccessful and she sadly died.

Issues included: (i) whether she should have been reviewed at hospital earlier; (ii) the adequacy of her examination and chest x-ray review; and (iii) delay in taking her for treatment. Experts: GP, Paediatric Oncology. Concluded: The Registrar failed to arrange an appointment at hospital as a matter of urgency following discussion with the GP. Examination and review of the chest x-ray were inadequate and the opportunity to obtain an accurate diagnosis and to commence treatment was lost. There was a delay by her mother in taking her for blood tests, which delayed her GP consultation. These issues more than minimally, negligibly or trivially contributed to TNB’s death. See media (Daily Mail and The Sun)