Patient safety

30.01.19

Hospital apologises after inquest reveals medical failings in sepsis death of baby girl

A hospital has apologised to the parents of a 15-month-old girl who died after she was sent home by doctors who failed to realise she had sepsis.

Evie Crandle died on 16 April 2018, two days after she was taken to Whiston Hospital in St Helens – but the toddler was sent home with ibuprofen and Calpol despite her parents suspecting she had an infection.

An inquest heard that there had been delays in Evie’s treatment and that medical professionals had missed opportunities to diagnose her with sepsis.

Evie’s parents Phil Crandle and Sam MacNeice told Liverpool Coroner’s Court that they had repeatedly asked medics to consider sepsis after their usually “playful” daughter had blue lips, a high temperature, was lethargic, and had been vomiting.

But hospital staff believed the baby girl had a urinary infection. The court heard that two paediatric nurses failed to correctly fill in a sepsis pathway tool, a procedure used to identify the disease.

Evie died two days after first attending Whiston Hospital’s emergency department and her parents said their daughter had been “let down in the worst possible way” by medical staff.

Dr Julie Hendry, the hospital’s assistant director of clinical improvement, said: “I would like to formally apologise to them on behalf of the trust.

“We fell below the standards expected.”

An internal investigation carried out by St Helens and Knowsley NHS FT highlighted a catalogue of failings during Evie’s care, revealing that there was a “missed opportunity” to diagnosis her with sepsis early on in the treatment.

The investigation found there had been delays in Evie’s treatment with documents and assessment forms not completed properly, as well as failings in recording observations, escalating her case to a senior doctor, communication between staff, and administering blood test and antibiotics.

At one point, hospital staff sent Evie home with ibuprofen and Calpol so her parents could collect a urine sample, but hours later she was back at the hospital as her condition had worsened.

Dr Hendry added that changes had been made since Evie’s death, including refresher training on sepsis for all staff and improved systems for flagging up potential cases.

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