The twice rescheduled inquest at The Coroner's Court, Beacon House, Whitehouse Road, Ipswich, into why one-day old Riyad Ali died on 16 July 2005 at Ipswich Hospital finally reconvened and concluded today (02 October 2020).
HM Coroner Mr Nigel Parsley’s conclusion was that Riyad died of metabolic acidosis of unknown origin. The coroner will record his death as natural causes.
Mrs Ali was originally advised by doctors that ‘genetic factors’ were the cause of her son’s death. No post-mortem was carried out because the family was advised that a skin sample would be sufficient to confirm cause of death. Unfortunately, this was not the case and both experts at the inquest and the coroner opined that the lack of post-mortem had contributed to their difficulty in ascertaining cause of death.
In his summing up, the coroner commented on the fact that, despite extensive genetic testing, no genetic cause had been found for Riyad’s illness.
The years of belief that the genetic make-up of the couple had in some way been responsible has had a terrible psychological and emotional impact on the family. Their distress was exacerbated when, several years later, Mrs Ali discovered that the Trust had launched an internal investigation into the cause of her son’s death, about which she had not been informed, nor had the hospital ever consulted her or shared their findings with the family.
The coroner was also critical of the Trust in failing to disclose the fact that they were investigating Riyad’s death and described this failure as unacceptable. He sympathised with Riyad’s parents saying that he could not imagine the additional heartache and grief they would have suffered as a result.
Originally scheduled to be held in July 2019 (some 14 years after Riyad’s death) the inquest was delayed until 30 January 2020 so that metabolic expert, Dr Champion could attend and give his evidence in person. HM Coroner, Mr Nigel Parsley, was about to deliver a narrative conclusion on the cause of death when he received a call from Dr Champion, who was having second thoughts about the safety of the evidence he had given.
On reflection, Dr Champion felt he could no longer say that, on the balance of probabilities, it was a metabolic disorder which caused Riyad’s death without the evidence of an endocrinologist investigating the possibility of adrenal insufficiency.
At court today, the endocrinologist’s evidence ruled out adrenal insufficiency. Dr Champion’s final comment when asked what he would write on the death certificate was that he would state cause of death as; “severe metabolic acidosis of unknown cause” and this is this the conclusion that the Mr Parsley reached today.
Mr Parsley also commented on the standard of Riyad’s care. He concluded that there were a number of missed opportunities to provide additional treatment to Riyad, including times when Riyad should have been considered as a medical emergency. But for the fact that 15 years have passed and medical and hospital practices will have changed over that time, Mr Parsley would have made recommendations for changes under Regulation 28.
Sue Prior, who has represented the family throughout, comments:
“The family are very grateful for the coroner’s comments on failures in care and how proper intervention would have provided more time for medical staff to diagnose and treat Riyad. The fact that, at the time, the family were advised that a post-mortem was unnecessary was clearly an error of judgement by the Trust and the decision not to consult the family in relation to their investigation was completely unacceptable and has significantly added to the family’s distress.”
Bilkis Ali, Riyad’s mother, said:
“It is of great relief to us that this inquest has finally concluded and that, having blamed ourselves for all these years, the conclusion is that there was no evidence that genetic factors caused Riyad’s death. We are saddened that there were failures in care by the Trust that meant that Riyad was deprived of the chance of diagnosis and treatment. We continue to consult with our legal team at Shoosmiths to consider the next steps but at this stage our inclination is to pursue a civil claim.”
Pictured above: Bilkis and husband Abdul with Baby Riyad at the time of his birth.