Introduction
One-week inquest into the death of a 13-year old girl who had a history of a worsening cough and weight loss. She was deemed not acutely unwell and was to be seen the following week. She was examined with nowhere to lie flat. A chest x-ray showed mediastinal mass, but was not identified upon review. She was discharged, but re-attended the next day. A tumour and fluid around her heart had progressed, surgery was unsuccessful and she sadly died.