Kate Pierce: Coroner seeks health board action after death
A report to prevent future deaths has been published by a coroner following an inquest into the death of a seven-year-old girl.
Kate Pierce, from Rossett, near Wrexham, died in 2013 after suffering brain damage from meningitis in 2006.
Her inquest in September heard she had been misdiagnosed when taken to hospital in 2006 and neglect had contributed to her subsequent death.
Coroner David Lewis has asked health officials to address his concerns.
In his report, published on Tuesday, Mr Lewis highlighted the uncertainty of the "circumstances in which a sick child should be seen by a senior paediatrician" before being discharged.
The inquest heard there was no recorded note of a specialist asking for a second opinion on nine-month-old Kate before sending her home from hospital, although he told the hearing it was "likely" he had.
Kate was brought back into Wrexham Maelor Hospital 36 hours later and was diagnosed with meningitis, which subsequently caused brain damage.
Mr Lewis also said he wanted clarity on the current practice regarding a second opinion.
He said: "The current system might therefore warrant a review, perhaps including consideration of best practice elsewhere, in other hospitals outside the health board, to see whether grounds for improvement exist."
Kate's father, Mark Pierce, said: "We are disappointed that there was a need for a report and that after 11 and a half years the trust still does not appear to have learned any lessons."
Betsi Cadwaladr University Health Board has 56 days to respond to the coroner's report.
Executive director Gill Harris said: "We would like to reiterate how very sorry we are for the distress this tragic incident has caused to Kate's family and once again offer them our sincere condolences.
"The health board takes all the findings of the coroner seriously and we are continuously working to improve the services we deliver."