Mayur Lakhani
Every healthcare professional and doctor should carefully read a report in The Times of 9 October 2002.1 This is a powerful and moving account of a mishap in the NHS that led to the death of a Ž veyear- old girl. The report is of a coroner’s inquest into the death of the child from an abscess in her throat that caused airways obstruction after surgery for the removal of a foreign body. Problems were encountered in getting the child to be seen at hospital following discharge and in misdiagnosis. The coroner concluded that substandard care was to blame for the tragedy
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