Charlie Goodwin, from Harleston, died at Addenbrooke’s Hospital in Cambridge after doctors discovered he had bowel malrotation. Charlie’s life could have been saved were it not for a registrar’s “unacceptable” assessment, the inquest has heard.

The surgical registrar was asked to review Charlie, who was severely acidotic, with a sudden onset of abdominal pain , distended abdomen and ground coffee vomiting. The registrar did not attend for nearly two hours. When he finally arrived, he was with Charlie for only 5 to 8 minutes, before incorrectly concluding that Charlie did not require surgery. In that time he did not review the medical notes prior to assessment, he did not lift up his shirt to examine Charlie’s abdomen and he did not listen to his bowel sounds.

The coroner concluded that this was an unacceptable assessment, which resulted in delay in getting Charlie to theatre, by which time it was not possible to save his life. The coroner entered a narrative conclusion reflecting these failures and wrote to the GMC, inviting it to review the registrar’s fitness to practice.

Read more here.


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