SALISBURY District Hospital has told an inquest it has taken steps to prevent what led to a teenager's death from happening again.
Thirteen-year-old Tanisha Baverstock died on January 31 last year after signs showing she had been suffering from lymphoma, a type of blood cancer, were missed.
On Tuesday, Wiltshire and Swindon coroner's court heard how a paediatric consultant who visited the teenager on January 29 and ordered a chest x-ray, made a "mistake" in reviewing the results of the test.
Dr Baird admitted that a shadowing in the left upper zone of Tanisha's chest "distracted" him from spotting "additional changes" to her lungs which signalled a more severe condition.
The teenager died two days later at Bristol Children's Hospital during a procedure to drain excess fluid from her heart.
READ MORE: Doctor involved in Tanisha Baverstock's case tells inquest of 'mistake' he made
Today, the final day of evidence, consultant radiologist Katherine Johnson and consultant paediatrician Rowena Staples at Salisbury District Hospital told the inquest that, "as a result of a root cause analysis", recommendations had been made to improve practice at the hospital.
These include making sure patients "have the full set of observations within 15 minutes of arrival", something that did not happen with Tanisha but that, according to Dr Staples, is now the case for 92 per cent of children attending the day assessment unit.
Other measures include the introduction of an integrated email process alerting clinicians of test results that need to be reviewed "with some urgency" and the overall improvement of the communication and discussion around urgent reports.
It comes after the inquest learned that Dr Baird had interpreted the x-ray results without the radiology report which was not available at the time of his assessment with Tanisha.
Outlining the improvements made since the teenager's tragic death, Dr Staples said the team had now achieved "a change in culture in our department".
"I believe we have minimised the risks as much as we can of a situation like Tanisha's happening again," added Dr Johnson.
Throughout the hearing, the inquest also heard from expert witness Dr Francis Mussai, a consultant paediatric oncologist from Birmingham Children's Hospital.
Dr Mussai told the court he thought Tanisha should have been seen by doctors at Salisbury hospital either the day the referral was made by her GP (January 25) or the day after.
He also went on to say that the signs missed by Dr Baird were "fairly obvious", particularly the enlarged heart and the widening of the mediastinum (the area that contains the heart).
If appropriate treatment to cure Tanisha's cancer had begun "any time before the 29th", it is likely she would have survived, he added.
Coroner Ian Singleton is due to deliver his verdict on Friday.
Comments: Our rules
We want our comments to be a lively and valuable part of our community - a place where readers can debate and engage with the most important local issues. The ability to comment on our stories is a privilege, not a right, however, and that privilege may be withdrawn if it is abused or misused.
Please report any comments that break our rules.
Read the rules hereComments are closed on this article