The preparation of what was supposed to be a routine MR scan is now under investigation following the death of a 14-year-girl, and provides a devastating reminder that MR safety is a topic as complex and diverse as the patients admitted for scanning.

Alice Sloman of Devon, U.K. was described by her parents as "laughing and singing" on October 16 when she went in for a scan at Torbay Hospital. Clinicians were investigating suspected water on the brain of the teen, who suffered from multiple health conditions, due to a number of headaches she had. While undergoing general anesthetic, however, Sloman suffered a cardiac event, narrowing the flow of oxygen to her brain and causing her organs to shut down.

"During the MR, her heart rate went sky high then plummeted a number of times and her blood pressure fell through the floor,” her mother, Sarah, told DevonLive. “What was supposed to be an investigation turned into a living nightmare. The liaise doctor said we should prepare for the worst.”

Sloman was rushed to Bristol Royal Hospital for Children and placed on life support. Though only given seven hours to live by doctors, she survived for three days. During that time, doctors discovered a previously diagnosed cardiomyopath condition, otherwise known as diseases of the heart muscle.

A possible diagnosis of Noonan syndrome was also made, with common symptoms including heart defects, restricted growth and unusual facial features. Sloman was autistic, a condition that often results in unique facial characteristics and has been linked to Noonan syndrome. She also was not producing growth hormones in her pituitary gland, forcing her to take artificial ones which her parents believe may have contributed to her poor health.

Sloman died on October 19, surrounded by her family. The circumstances around her death are being looked into. “We are currently investigating the very tragic death of Alice,” Jane Viner, chief nurse at Torbay and South Devon NHS Foundation Trust, told DevonLive.

In response to their daughter’s death, Sarah and her husband, Nathan, are now advocating that every child’s heart be tested prior to undergoing a general anesthetic, and that providers ensure proper preparations are in place for patients undergoing MR, particularly higher acute patients.

Tobias Gilk, executive with the radiology-centric architectural firm, RAD-Planning, chairman of American Board of Magnetic Resonance Safety, and founding principal of his own enterprise, Gilk Radiology Consultants, chalks the problem up to decades of mainly imaging relatively healthy outpatients.

“For the longest time, there weren't significant concerns about anesthesia or its complications,” he said. “Because we largely excluded emergent and trauma cases, ICU patients and post-surgical patients at those times, we weren't really doing anything to our patients other than imaging them. We developed a sense that people simply couldn't get hurt from MR imaging and felt we didn't need support infrastructure, or ACLS-credentialed people,” he told HCB news. “In ways small and large, we have failed to prepare for risks even though MR has grown increasingly stronger, and our patients have increased in acuity and the degree of intervention that we subject them to.”

He adds that while it is not yet known if MR played any role in the tragedy, providers should still take note and work to ensure patient care and scan efficiency are safely planned out long in advance, with protocols and resources in place for any type of emergency situation.

“What are your current most precarious patients that will be accepted for MR? If these same patients were to undergo an examination anywhere else in the hospital, what would your minimum expectations for their care be? Are the elements of care that you'd expect to be minimum to this patient's care elsewhere, in MR? Do you have trained and qualified individuals responsible for overseeing processes for emergent patient care in the MR suite? This event should focus our minds to the question of 'could something similar happen here?'”