Teenager Died After “A Number Of Missed Opportunities And Failures” In His Care

Lawyers Urge Hospital To Immediately Implement Coroner’s Recommendations To Improve


Medical law experts representing the family of a teenager who died when doctors failed to spot major internal bleeding have urged an NHS Trust to implement a coroner’s recommendation that a consultant should be present in the accident and emergency department at Leeds General Infirmary (LGI) 24 hours a day.

The call from specialists at law firm Irwin Mitchell comes after an inquest at Wakefield Coroner's Court found that a boy who suffered fatal internal bleeding just four days after being sent home with painkillers by doctors at the hospital would have had a greater chance of survival had he been admitted and properly monitored. 

Staff at LGI had previously been warned by a doctor at Wharfedale Hospital, who had arranged for an ambulance transfer to LGI for the boy, that the situation was very serious and he needed urgent treatment. Despite this, he was not seen for three hours and was then sent home without seeing senior staff.

Coroner David Hinchliff detailed “a number of missed opportunities and failures” in his narrative verdict on the death and also stated that, as the largest teaching hospital in England, Leeds “ought to have permanent consultant cover in its accident and emergency department”.

Jacob Long from Rawdon, Leeds, died on 25 May 2009, aged just 15, following a rupture in a major vein which caused internal bleeding amounting to around 38 per cent of his total blood volume.

His mother, Sarah Long, has spoken out about the horror of watching her son die as he was rushed by ambulance to Leeds General Infirmary following a collapse just four days after doctors sent him home with paracetamol saying they believed he had a chest infection.

The verdict at the inquest criticised the Hospital for discharging Jacob too early despite him not being seen by more senior members of staff and his x-rays and investigations showing some irregularities. There were also concerns over the speed of treatment as he was not seen for three hours on arrival even though he was transferred as an emergency patient by ambulance.

The coroner stated that Jacob was “inappropriately discharged” from hospital and that “had he been an inpatient at the time of his catastrophic bleed...his chances of successful resuscitation and survival would have been greater”.

Anna Bosley, a medical law expert at Irwin Mitchell who successfully represented Sarah and her family in a civil claim against Leeds Teaching Hospitals NHS Trust, said: “What happened to Jacob was tragic and his family are still distraught.

“There was a catalogue of failures in communication in this case and the end result was that Jacob was sent home with the diagnosis of a chest infection but he collapsed and died four days later with a very serious condition. The Trust has apologised for Jacob’s death and the internal investigation carried out was highly critical of the missed opportunities to diagnose and treat Jacob.

“However, this situation should never have arisen in the first place and the Trust needs to ensure that systems are put in place so that such catastrophic breakdowns in communication do not happen again to prevent any more avoidable deaths.”

Jacob first saw a doctor at Wharfedale Hospital on 20 May 2009 who recognised how seriously ill he was and arranged for an ambulance to take him to LGI for further diagnosis and treatment. He gave a letter to the paramedics and told them the urgency of the situation, and then rang ahead to warn the hospital that Jacob was on his way and that it was an emergency.

However the staff member who took the call failed to act on it and it took almost three hours for Jacob to be examined after he was placed in a cubicle rather than taken to the appropriate treatment rooms. He was then sent home despite not being seen by more senior members of staff and his x-rays and other investigation results showing some irregularities.

Four days later in the early hours of Monday morning (25 May 2009) Jacob was found by Grandfather Fred Long slumped over in his room. An ambulance was called and paramedics carried out CPR when they arrived before rushing him Leeds General Infirmary.  Both Sarah and Fred Long witnessed the paramedics trying to resuscitate Jacob in the back of the ambulance and Sarah went in the ambulance with Jacob to the hospital. Jacob was pronounced dead on arrival at the hospital.

Jacob was the eldest of three children and lived with his mother and her partner Stuart Fisher.  He had a very close relationship with his grandparents and would often stay over at their house.

His mother Sarah Long, who is absolutely devastated by Jacob’s death, says she wants assurances that lessons will be learned so that others do not suffer as they have. She said:  “It was a long and harrowing inquest and it was tough to listen to the fact that Jacob’s death may have been avoided with better communication between staff and better treatment.

“Nothing can ever prepare you for losing a loving son, especially when you know it could have turned out differently. Hearing the failures spelt out like this is something I hope no one else ever has to go through. Nothing will ever be able to bring Jacob back but I really hope the NHS Trust has now made improvements so that others don’t suffer as Jacob and our family has.”