Overview

• Assistant coroner Dr Karen Henderson found staff failed to spot Rose’s clinical deterioration and did not transfer her to St George’s Hospital for surgery.
• An autopsy determined Rose suffered a caecal volvulus causing intestinal obstruction and bowel ischaemia that required specialist treatment.
• The report noted Rose’s mother was not offered a Learning Disability Liaison Nurse and was excluded from key care decisions.
• Royal Surrey County Hospital NHS Foundation Trust issued an unreserved apology and pledged to implement all coroner’s recommendations.
• The coroner warned of a wider hospital culture that risks discriminating against disabled children by undervaluing parent or guardian input.