A Chingford family’s quest for the truth over the death of a severely autistic woman has received a major boost after a coroner ruled she died as a result of "gross failure" by her GP and hospital staff.
Robin Kitt Callender, 53, formerly of Alpha Road, Chingford, died less than 24 hours after being admitted to King George's Hospital in Goodmayes in 2012 following four months of intermittent vomiting, diarrhoea, and significant weight loss.
A post-mortem gave Ms Callender’s cause of death as cardiac arrest and septicaemic shock as a result of haemorrhaging from inflammatory bowel disease.
Today, Coroner Nadia Persaud ruled the death was due to natural causes contributed to by neglect as a result of "gross failings" in the run-up to her collapse on May 22.
Ms Callender could not coherently speak, read or write and was partially sighted.
Her vulnerable and anxious state made it "very difficult to communicate and doctors were therefore unable to assess her capacity", Ms Persaud said.
Staff at Perrymans Care Home in Abbey Road, Barkingside, where she was being cared for, were concerned Ms Callender's health was not improving and took her on three occasions to see GP's Dr Hussain and Dr Akpotar at The Palms Medical Centre in Ilford.
She was also admitted to King George accident and emergency department on March 22, but was discharged without an assessment.
During all four visits between February and May, her condition was not diagnosed and the required tests, including blood pressure, temperature, pulse and an abdominal examination, were not collectively carried out.
Independent surgical expert and clinical lead for colorectal surgery at the Royal Free Hospital, Professor Marc Winslet, said Ms Callender’s death would have been avoided if she was not discharged from King George’s Hospital on March 22, and if her GP had taken a blood test on May 14.
Ms Callender was reluctant to have medical examinations without her sister Karen Callender Caplan, 68, of Alpha Road, Chingford, present.
But Mrs Callender Caplan was never told of her sister's ill health until the day before her death.
Concluding the inquest, Ms Persuad said: "There was a failure by her GP on May 14 to take proactive steps to investigate the cause of Robin's recurring symptoms.
Robin Kitt Callender at Perrymans Care Home in 2011
"In my opinion, there were a number of factors in Robin's case which required a blood test to be taken on and prior to May 14.
"The fact that Robin might not have co-operated with a blood test is not a sufficient reason to defer undergoing sufficient investigations.
"Had a blood test been carried out on May 14, the results were likely to have shown raised inflammatory markers and Robin admitted to hospital.
"It is likely her death would have been avoided.
"Discharging Robin from hospital on March 22 to unqualified carers who were clearly concerned about Robin and had visited healthcare practitioners to seek help in two days provided no effective safeguard.
"There was a gross failure to provide basic medical attention."
Following the verdict, the Mrs Callender Caplan released the following statement.
"From the day she was born, our family was devoted to and extremely protective of Robin because of her health problems. Medical examinations were always difficult for Robin as she did not like to be in an unfamiliar place with a stranger, or to be touched by people she didn’t know and trust.
"I now know that in the lead up to her death Robin was going back and forth to see her GP who, according to the coroner, missed an opportunity to save my sister’s life.
"Yet I am sure that if I, or my sister Sherry, had been with her she would have been properly examined and her death could have been prevented, as we understood how she communicated and expressed pain better than anyone else.
"At the very least, we would have advocated for sedation to facilitate a proper examination.
"Since Robin’s death I have been desperately trying to get to the bottom of how she became so ill, why she never received the care she needed and how it got to the point that she was at death’s door before anyone bothered to contact me.
"Even at A&E they just sent her home because she was being difficult.
"It is too late for my younger sister but it is not too late for the thousands of vulnerable and unprotected Robins still out there.
"There is a growing crisis in the care of vulnerable people and I want to create a 'Robin’s Law' which would make it a criminal offence for a care home not to inform a family if someone in their care, who lacks capacity, falls ill and subsequently dies."