Girl died from 'rare complication after tonsil op'

Amber had her tonsils and adenoids removed in a planned operation

A five-year-old girl died after "a known, but very rare complication" after a routine operation, a coroner has found.

Amber Milnes, who had cyclical vomiting syndrome (CVS), died at the Royal Cornwall Hospital on 9 April 2023 after an artery ruptured following surgery to remove her tonsils, an inquest heard.

At Cornwall Coroner's Court on Thursday senior coroner Andrew Cox said he expected clinicians without knowledge of the syndrome to consult those that did so full and informed parental consent could be given.

In a statement, which opened the inquest on Wednesday, Amber's mother Sereta and father Lewis Milnes, said Amber had been their "magical little princess".

'Push the pause button'

CVS meant Amber had prolonged periods of severe nausea which could sometimes last for days, the inquest heard.

Paediatric pathologist Dr Andrew Bamber had told the inquest on Wednesday Amber had died as a result of "a massive haemorrhage with aspiration of blood" after infection at the site of the surgery had ruptured an artery.

The coroner agreed with this finding and said he considered it "incumbent on a medical team to educate themselves" when treating "a child with a complicating and complicated condition".

He said he expected clinical colleagues without knowledge of CVS to consult with those that do so parental consent could be informed.

He said: "When you come across something you don't know about, push the pause button."

The inquest into Amber's death began on Wednesday

On Thursday, the inquest heard from an independent expert witness, Mr Simon Carr, a consultant in urgent throat surgery based in Sheffield Children's Hospital.

He said: "If Amber had reduced oral intake because of CVS that would put her at greater risk of developing infection and bleeding as a result of that infection.

"A conversation about the increased risk to Amber should have taken place," he said.

He told the inquest: "It is an uncommon syndrome, it is an uncommon situation, perhaps he [the surgeon] could have consulted with colleagues on the day."

Mr Cox said Amber had been sick more than 20 times in the 24 hours following the operation and he asked Mr Carr whether she should have been readmitted earlier.

Mr Carr said it was difficult to say whether this would have changed the course of events.

The surgeon said it was "an extremely unfortunate and very sad case."

Amber was five years old when she died

In a statement after the inquest, Amber's parents said: "As her parents we will always feel that Amber should still be with us."

They said they felt their child should have stayed in hospital overnight after the operation as they had requested or at least been readmitted early the next morning when she began suffering with a CVS episode.

"We still feel her condition wasn't understood enough.

"We understand her death in this way was incredibly rare but it never for a moment crossed our minds that she might die from having her tonsils out."

They urged parents to remember Amber when their children faced surgery.

"If surgery is needed then do go ahead but if you are worried, don't be afraid to trust your instincts and speak up or ask questions, and work with the doctors.

"Remember that no operation is risk-free, however common it may be."

'Utterly devastating'

A statement from the NHS Cornwall and Isles of Scilly Integrated Care Board said it fully accepted the coroner's findings.

Dr Merry Kane, chief medical officer at the hospital. said: "Our hearts go out to Amber's family; the death of a child is utterly devastating.

"We have all learned from Amber's tragic death."

She said since Amber's death new guidelines had been introduced on caring for children with sleep apnoea, which causes disturbed sleep patterns, after an operation to remove tonsils and adenoids.

"We will continue to do everything we can to increase awareness of CVS," the hospital added.