Who was Louis Cartwright?
Louis Cartwright was a 17-year-old school student from London. He lived at home with his mum Jackie, his dad Ian and his sister Eve and he stayed at his special school during the week.
The teenager was a big music fan and loved to sing and dance. Dancing in the kitchen to his hero Elvis Presley was a favourite way to spend his time. He also adored the musical Matilda.
He was a natural peacekeeper. Love, calmness and friendship were important to him. He was never happier than when everyone else was happy and smiling.
The young Londoner had a great and full life. He was not materialistic but a fan of simple pleasures. He was partial to a toasted bagel or a slice of chocolate cake and was also a fan of a cooked breakfast in his local café although, when it came to a fry-up, he was not keen on tomatoes or mushrooms.
Change in health
Louis had Down syndrome and was autistic. He had had surgery as a baby to repair a hole in his heart and made a full recovery.
Louis saw his cardiologist in June 2022 and was starting to transition from child to adult services. There was talk of him needing valve replacement surgery at some point but this was not required immediately.
In January 2023, Louis’ parents noticed he was looking pale. He wasn’t as interested in doing things as he normally was and was more tired. His mother made an appointment for him to see his GP on a Friday when he got home from school.
Then, in the middle of the week, the school asked his family to collect him as he was unwell. Jackie and Ian were worried about him and took him to A&E at the Princess Royal University Hospital in Bromley.
The department was very busy so they had to wait for five hours before being seen. Eventually, in the early hours of the morning, Louis let the doctor listen to his chest and take some measurements, but he did not want a blood test done.
The doctor said she knew her patient would not get a bed or trolley that evening so she agreed his parents would take him home and bring him back the next day for a blood test.
The next day, he was back to hospital to have a blood test. A doctor said he looked a little scared, but he did not look unwell. He did not take any formal observations.
The doctor tried to do a finger prick blood test, where blood is squeezed from the finger. It did not work. Jackie and Ian had asked if their son could be sedated to have blood taken but the doctor said this was not necessary.
He recommended dietary supplements and his parents talk to the GP to arrange for a blood test to be done in the community.
Louis’ parents took him home but he did not get any better. A blood test was arranged for nine days later, but the young man was too ill to attend that appointment.
A GP came out to at 7pm that evening. She told the court Louis was placid and silent, allowed her to examine him and there were no findings that made her concerned.
She did not consider he needed urgent hospital treatment or admission and she told Jackie that her son was clinically stable.
Louis Cartwright died at home in the early hours of the next morning.
Inquest
The court heard evidence from his parents and the doctors who treated him.
It also heard from an expert, Dr Maximillian Habibi. He said that, had blood tests been done when the patient first went to hospital, he would most likely have survived.
“Louis was not as unwell as he was later. However, I think on balance, those blood tests would have pointed the way to allow a diagnosis to be made, and it is my belief that diagnosis was a treatable one,” he said.
Louis was allowed to die due to his disability. It was due to his disability no blood test was taken, no diagnosis identified and no treatment offered
Habibi also told the court that he could have been sedated to have his blood taken; this is not usual practice but he had done it before.
The coroner at South London coroner’s court found that Louis Cartwright’s medical cause of death could not be ascertained. He decided that the death was from natural causes.
The coroner said, because he did not know what had caused Louis’ death, he could not find that anything contributed to it.
He thought attempts to obtain blood samples were “reasonable”, in terms of what was done and when. He also said he did not think blood tests would have provided a diagnosis, even if they had been taken.
Attempts to test
Princess Royal University Hospital is part of King’s College Hospital NHS Foundation Trust.
“We would like to extend our condolences to Louis’ parents once again for the death of their son,” it said.
“While we were treating Louis, several attempts were made to obtain blood, so that tests could be carried out to try and ascertain the reason for him feeling unwell but, unfortunately, they were unsuccessful. Given his clinical presentation, which was clinically stable, sedation was deemed inappropriate at that time.
“The safety and dignity of patients with disabilities is of paramount importance, and we provide training to our staff to ensure appropriate care is provided.”
The family believed he was allowed to die: “Over the last two and a half years, three different causes of death were suggested for why Louis died. Ultimately the coroner said he could not ascertain the cause of Louis’ death. We can. We believe he was allowed to die due to indifference.
“Louis had Down syndrome so the medical staff could not ask him questions and would not listen to us, his parents.
“If he had been a 17-year-old boy who articulated he did not feel well, he would not have been sent home from hospital.
“We believe Louis was allowed to die due to his disability. It was due to his disability no blood test was taken, no diagnosis identified and no treatment offered.”
The parents had asked that he be sedated to give blood in hospital, but this did not happen.
It is not uncommon for people to find it difficult to give blood; they may be scared of needles or have had a bad experience.
Back in 2017, Public Health England issued guidance on blood tests for people with learning disabilities, which includes reasonable adjustments and case study examples.
If an adult is unable to give blood then a meeting to ensure decisions are taken in their best interests should be held and options for taking blood discussed.
