A doctor who reviewed a four-year-old Chesterfield girl before she was discharged from hospital but died hours later from 'sepsis' has said: "I wish I had done more."
Gracie Ella Foster, of Holland Road, Old Whittington, attended Chesterfield Royal Hospital for a routine operation to have her enlarged tonsils removed - but the procedure was cancelled when she fell unwell on the ward - and she was sent home with what was believed to be a viral infection.
But later that evening, on October 21, 2015, her condition deteriorated and she passed away at Sheffield Children's Hospital after being rushed there by her grandmother.
Dr Tim Ubhi, a consultant paediatrician, who was working at the Royal hospital at the time as a locum consultant, reviewed Gracie to see if she required antibiotics after being told that she had been diagnosed with tonsillitis and discharged from hospital following the cancellation of her operation.
During an ongoing inquest into Gracie's death, Chesterfield Coroners' Court heard on Tuesday that Dr Ubhi checked Gracie's tonsils but did not view her medical history or carry out any further observations or examinations. He said this was because he was not undertaking a full referral and was simply responding to a request by a nurse to make an assessment on whether Gracie needed antibiotics, to which he confirmed she did not.
Dr Ubhi said: "It was a casual request for a child who had been discharged and diagnosed.
"The nurse who was doing it was doing it out of good intentions.
"In retrospect I wish I had done more but I answered the question that I was asked and I answered it fully."
He added: "Had I on my examination felt there were any significant signs of sepsis I would have acted on them."
Dr Ubhi said that had it been a full referral then he would have checked Gracie's full medical history and carried out further examinations and observations and she would have been kept in hospital.
Dr Ubhi, a lecturer for undergraduate paediatricians, was asked on the balance of probabilities, whether Gracie would have survived had this happened, he replied: "If we had given her antibiotics at 3pm she would have survived."
Senior coroner, Dr Robert Hunter, then asked Dr Ubhi whether they could agree that Gracie was 'in the intermediate category for risk of serious illness at the very least', to which he responded: "Yes, I agree."
Dr Hunter went on to say: "She ticked a number of the boxes to suggest meningococcal septicaemia."
Dr Ubhi added that after reflecting on that day in October 2015 'there were 10 different factors that contributed to her sad demise' and 'system errors' at the Royal at the time but said he believed these to have been addressed.
Earlier on Tuesday the inquest heard evidence from Shereen Macdonald, the nurse who asked Dr Ubhi to assess Gracie to see if she needed antibiotics.
The court heard that Ms Macdonald did take Gracie's temperature but did not carry out a formal clinical review which was described as 'basic nursing care'.
But Ms Macdonald did give 'safety net' advice to Gracie's mum, Michelle, informing her to come back to hospital if her daughter's condition deteriorated and gave advice on times for her next dosage of paracetamol and ibuprofen.
The inquest previously heard that Gracie arrived at the Royal hospital 'happy, excited and joyful' and was her normal 'chatty' self and was looking forward to going to her grandmother's home for treats after her operation.
But as the morning went on she became 'mardy' and let out a cry while in the playroom before becoming sleepy.
Her condition worsened and she complained of a sore throat, a headache and she had a high temperature recorded as 40.1.
She vomited 30 seconds after taking her pre-operation medication.
As a result, her operation was cancelled and her mum carried her out of the hospital 'floppy'.
Ms Foster, believing her daughter had a minor viral infection, took Gracie to her grandmother's while she went to her son's school disco.
But sadly Gracie's condition worsened and she died that evening at Sheffield Children's Hospital after she continued to vomit and her grandmother found two non-blanching spots on her body.
A post mortem concluded that Gracie died of Waterhouse-Friderichsen syndrome, meningococcaemia and neisseria meningitidis infection.
The inquest concludes on Friday.