Death of Chesterfield girl, 4, from sepsis, was 'preventable' after 'gross failures' by hospital, coroner concludes
The death of a four-year-old Chesterfield girl who passed away from sepsis just hours after being sent home from hospital was 'preventable' after 'gross failures' by healthcare professionals, a coroner has concluded.
Gracie Ella Foster, of Holland Road, Old Whittington, died on October 21, 2015, at Sheffield Children’s Hospital.
Just hours earlier she had been at Chesterfield Royal Hospital to undergo a routine operation to have her enlarged tonsils removed - but the procedure was cancelled when she developed a fever while on the ward.
Her condition was not investigated properly and she was discharged by the Royal without 'basic and routine procedures' being carried out.
Gracie died hours later.
Coroner Dr Robert Hunter, recording a narrative verdict, told Chesterfield coroners' court today: "As such, Gracie's death was a preventable death.
"There were gross failures by the attending health care professionals and as such, Gracie Ella Foster died of natural causes contributed by neglect."
Dr Hunter said that had the relevant medical checks such as vital signs, clinical history or examinations been undertaken Gracie would, on the balance of probabilities, survived, adding that these were 'total and complete failures' and 'missed opportunities'.
Dr Hunter also said the Royal had no systems in place to address the issue of a well child admitted for elective surgery becoming acutely unwell on the ward before surgery took place and no system in place to guarantee the medical review of a child, by a paediatrician, before discharge from hospital.
He added: "Consequently the seriousness of her condition was underestimated, went undiagnosed and therefore untreated."
Earlier in the inquest, Gracie's mum, Michelle Foster, spoke of her ‘trust’ in the Royal and how she felt ‘lucky’ that Gracie happened to have fallen ill in hospital - but she added she now felt ‘stupid’ for thinking that way.
A tearful Ms Foster, of Old Whittington, said: “When I carried her away from hospital I thought she was alright, but I took her away to die basically.”
The court previously heard that Gracie, a pupil at Lenthall Nursery and Infant School in Dronfield, arrived at the Royal as a 'fit and well lively child'.
Gracie chatted to staff and was looking forward to having treats at her grandmother’s house after her operation.
But while waiting for her operation, she started to feel unwell.
She became unusually quiet, let out a cry in the playroom and was sleepy, as if she had been ‘sedated’, Ms Foster said.
Gracie's temperature was recorded as 40.1, she vomited her pre-operation medication within 30 seconds and complained of a sore throat.
Her mum carried her out of the hospital ‘floppy’.
Gracie’s mum, believing her daughter had a viral infection, took her to her grandmother’s house as had been planned, while she went to her son's school disco.
However, Gracie’s health deteriorated further - she kept vomiting and her grandmother found two non-blanching spots on her body - and so rushed her to Sheffield Children’s Hospital.
Gracie passed away at Sheffield Children’s Hospital that evening just after 10.30pm.
A panel of experts concluded that Gracie's fever was the start of invasive meningococcal disease and that she required a full set of observations as she was found to have a high temperature.
The experts said that had these taken place, which they should have, Gracie would have been kept in hospital.
Another child at Gracie's school had been diagnosed with meningococcal disease just weeks before, but Public Health England did not send out an alert because there had not been an outbreak of the illness and so the Royal was not aware that Gracie may have come into contact with the disease. Dr Hunter is set to write to Public Health England in the light of Gracie's case.
But Ms Foster earlier told the inquest that Gracie was in a diffferent part of the school from the boy and her symptoms were nothing like what he had.
A post-mortem concluded that Gracie died of Waterhouse-Friderichsen syndrome, meningococcemia and neisseria meningitidis infection.
Dr Hunter concluded that Gracie died of natural causes, contributed to by neglect.
Addressing Ms Foster and her family, Dr Hunter, said: "It is obvious that a light has gone out in your life. When things get difficult, know that the life you had with Gracie will get you through the bad times."
Carrolle White, of Nelsons Law firm, said: “Nothing will bring Gracie back - her early, tragic and avoidable death is something from which her family will never recover."
A statement from Chesterfield Royal Hospital said: "Our thoughts and heartfelt condolences are with Gracie’s parents and family. Her death is a tragic loss and we appreciate that this remains a difficult time for all of them.
"We are truly sorry that whilst Gracie was in our care that day we missed opportunities to carry out a more thorough assessment of her condition before we allowed her to go home.
"We are pleased that in delivering his verdict today the coroner noted the learning we have put in place, under our own initiative - and that he was satisfied we ‘have taken all reasonable precautions to prevent further recurrence’.
"We are however deeply saddened that the coroner concluded there was ‘neglect’ on our behalf. We strive to provide exceptional quality care. We regret that in Gracie’s case we did not meet the high-standards of care that she and her parents were entitled to expect and receive.
"As the inquest has established, we learnt some important lessons in reviewing what happened to Gracie, putting new measures and procedures in place to change and improve how we look after children attending hospital for booked operations.
"We know that these changes, whilst benefiting other young patients and their parents and carers, do not alter the circumstances Gracie’s family are coping with. We hope however, that they offer some small comfort to them as they continue to cope with the loss of their daughter.
"And finally, whilst we have already acted after Gracie’s death, we will reflect on the coroner’s verdict and its conclusions - to ensure that we have taken every opportunity to learn from what happened; and to make sure we have done everything we can to prevent it happening again."