Tragic Islington baby Axel Peanberg King verdict: consultation ‘wholly inadequate’

PUBLISHED: 11:25 01 March 2013 | UPDATED: 13:07 04 March 2013

Baby Axel Peanburg King died after being seen several times by out-of-hours GP service, Harmoni. Picture: PA

Baby Axel Peanburg King died after being seen several times by out-of-hours GP service, Harmoni. Picture: PA


The devastated parents of a baby who died after being sent to the back of a queue in a GP surgery want to stop other children ‘slipping through the net’.

Axel Peanberg King, from Islington, was just seven weeks old when he stopped breathing waiting for a doctor at the Harmoni Centre at the Whittington Hospital, in Magdala Avenue, Archway.

He was only treated when an off duty nurse spotted his condition – by then it was too late.

A two-day inquest into his death finished last night with Coroner Dr Shirley Radcliffe branding the initial telephone referral from Harmoni “wholly inadequate” with “insufficient questions”.

Now Axel’s parents, Linda and Alistair, are considering action to stop the same fate befalling other children.

In a statement issued following the inquest, they said: “We believe there are still many questions to answer about the safety of the service provided by Harmoni.

“We do not believe that anyone hearing all the evidence in this case could have full confidence in Harmoni’s out of hours services.

“We are now considering all our options to prevent any other children from falling through the net.”

Ellen Parry, from the law firm representing the couple, said: “Both Linda and Alistair want to know how their otherwise healthy baby, after repeated visits and calls to this privately-run clinic, died from a treatable illness, a death that we believe was entirely preventable.”

The inquest heard how Axel was taken to the family doctor in October last year, who diagnosed a probable viral infection.

The next night he hadn’t improved so Mrs Peanberg King, 35, contacted Harmoni and was seen by a doctor who said Axel’s vitals signs were good.

Fighting back tears, she told the hearing: “I had allowed myself to be reassured, but my gut feeling was taking over.”

She and Mr Peanberg King, 36, called Harmoni the following day, but when Dr Muttu Shantikumar called them back he was “very abrupt and very short” as he made them an routine appointment – which Dr Radcliffe said should have been made urgent.

There were six people in front of Mrs Peanberg King when she arrived at Harmoni.

She said: “I could not see his chest move, so I pinched his foot but did not get a reaction.

“She [the receptionist] explained there were still three people in front of me, so I sat down again.

“An off-duty paediatric nurse was looking at him, she said: ‘you need to go through straight away’.”

“When a doctor came to see me in the relatives’ room, I knew the battle had been lost.”

Recording a narrative verdict yesterday evening, Dr Radcliffe said: “The telephone conversation was wholly inadequate.

“It lasted only one minute and the entries made are clearly at odds with the evidence from Mrs Peanburg King.”

She added: “It is impossible to say whether intervention at an earlier stage would have changed the tragic outcome.”

Harmoni came under fire last year after the Gazette reported a sick newborn baby was left to wait for more than an hour in a late-night GP surgery on Christmas Eve – only for the parents to be told the doctor had already gone.

Then in January Harmoni bosses were hauled in front of Islington Council after Fred Kavalier, a former lead clinician at the company, resigned and wrote to directors about his “urgent concern about the quality and safety of the service”.

Dr David Lee, medical director for Harmoni, expressed his sympathy for the Peanberg King family and said the company would be taking full regard of the coroners findings.

He said: “The death of such a young child is always a particularly traumatic experience for all concerned. In response to this we have undertaken an exceptionally detailed review of the circumstances.”

He added: “We have jointly assessed how we can provide additional support to our out-of-hours GPs dealing with very young babies and have further improved communication between the services so that if there are concerns these can be highlighted and addressed quickly.”


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