Salisbury hospital doctor involved in Tanisha Baverstock's case tells inquest of 'mistake' he made

Dr Jim Baird told Wiltshire and Swindon coroner's court that he misinterpreted the results of a chest x-ray carried out on January 29 2019 – two days before the teenager's tragic death.

Tanisha, who had just moved from Salisbury to Calne, had been referred to the hospital's day assessment unit after suffering from a persistent cough, breathlessness and weight loss previously attributed to a chest infection.

READ MORE: Mum of 13-year-old Tanisha Baverstock had chance to say goodbye 'taken away', inquest hears

On the day of the assessment, Dr Baird arranged for an x-ray to be conducted. However, when the results of the examination came back, the paediatric consultant failed to spot "significant changes" that could have led to a cancer diagnosis.

He told the inquest: "I reviewed the x-ray and on the x-ray appearance one of the clear things to see is some shadowing in the left upper zone. With my review of that and having reflected on the case, that finding may have distracted me from clearly seeing additional changes in her mediastinum [the area that contains the heart] and cardiac contour."

Mr Baird stated that the changes to the left upper zone of Tanisha's chest were "consistent with a chest infection or pneumonia" and that he was "wanting to try a two-week course of antibiotics to see if they would improve her symptoms".

While giving evidence in court, the consultant also admitted that, due to Tanisha's mother needing to leave the hospital by 1.30pm to collect her children from school, "the need to complete the assessment review in a discreet time period may have attributed to me making a mistake in reviewing the x-ray".

Ultimately, concerns about Tanisha's test, which the inquest was told showed an enlarged heart, a widening of the mediastinum, shadowing on the left upper zone and a slightly deviated trachea, were raised by radiologist Katherine Peace who, the day after the appointment, discussed the findings of the examination with two other consultants.

Wiltshire and Swindon coroner's court.

One of them, Dr Rowena Staples, subsequently called Ms Baverstock to inform her of a "more solid area within the chest that was causing us concern" and advise her to take Tanisha back to Salisbury's day assessment unit "urgently".

This is disputed by Ms Bavestock who on Monday told the inquest that she was instructed to wait for a further call advising her on whether to take her child to Bath or Bristol hospital.

After receiving a message from Dr Stephen Lowis, consultant paediatric oncologist at Bristol Children's Hospital, who had been made aware of Tanisha's case by the team at Salisbury, Ms Baverstock took her daughter to Bristol's A&E.

Dr Lowis told the inquest how, at that point, the 13-year-old needed to be seen "as soon as possible" as her case had become a "medical emergency".

Following an echocardiogram carried out the next day, January 31, doctors were alerted to an excess of fluid around Tanisha's heart "that needed to be drained immediately".

"This is not something routinely done at all," said Dr Lowis after outlining the procedure carried out by doctors.

He added: "There was a significant possibility that things could go badly wrong. There was a risk that she could die as a result or during the operation."

After losing consciousness during the course of the procedure, all attempts to resuscitate Tanisha, including an open-chest cardiac massage and 12 cycles of adrenaline, failed.

The inquest heard Tanisha was "the first and only patient we have had to resuscitate in that manner".

Dr Lowis also said the teenager was affected by a type of lymphoma that is "definitely curable" through chemotherapy and radiotherapy. He estimated she had been living with it "for more than a month".

At the end of his evidence, the oncologist offered his condolences to Tanisha's family, adding: "This was an extraordinarily traumatic time for the family and something which, thankfully, we rarely see but we responded to the best of our abilities."

The inquest continues.