‘Catalogue of errors’ led to hospital death of two-year-old girl from flu, inquest finds

A coroner has ruled that Cristiana Banciu likely would have had a better chance of survival had the hospital she was at paid better attention to her.

The two-year-old was a month shy of her third birthday when she died on 8 January 2020, at King’s College Hospital in Denmark Hill, south London, where she had been transferred after suffering a rare response to the flu.

Cristiana was at the Princess Royal University Hospital (PRUH) in Orpington just two days before, on 6 January, where the inquest at South London Coroner’s Court found she had been highlighted as a patient of concern “multiple times”.

It was then revealed that an investigation by the King’s College Hospital NHS Foundation Trust found there was a failure to adequately monitor Cristiana on the ward, a failure to detect her declining neurological condition, and a failure to act and escalate on her low Glasgow Coma Score (GCS).

The GCS is used to describe the extent of impaired consciousness in all types of acute medical and trauma patients, and assesses people according to three aspects of responsiveness: eye-opening, motor, and verbal responses.

Assistant coroner Jacqueline Devonish subsequently ruled Cristiana would have had a better chance of survival had she been transferred to intensive care sooner. She added the failure to record Cristiana’s GCS was “very serious indeed”.

“It seemed to me that there was a lack of attention and a lack of knowledge which had directly contributed to this little girl’s death,” she said at the inquest, adding she was of the view healthcare professionals “failed to provide basic medical attention”.

She said these were “very basic neurological observations that needed to be undertaken” and those results properly reviewed by a senior clinician.

“In my view that’s a gross failure,” she judged.

However, Ms Devonish said the law does not support a finding of neglect because there is no evidence that Cristiana would have survived had she been treated sooner.

“Baby Cristiana died from a rare response to influenza in circumstances where the decline in her responsiveness, Glasgow Coma Score (GCS) of eight and progressively sluggish pupils had not been recognised,” she said in her narrative conclusion.

“There was a consequential delay in transfer to the paediatric intensive care unit. It is not possible to say on the balance of probabilities whether she would have survived if transferred sooner.”

“But she would, probably, have had a better chance,” Ms Devonish said.

Addressing the family, the coroner went on: “I’ve seen the picture of baby Cristiana on your T-shirt. She’s absolutely beautiful.”

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Acknowledging this was “an extremely sad case”, Ms Devonish commended the family for recognising “early on that there was something seriously wrong” and said “it’s a pity that those treating her didn’t also recognise that”.

She said there had been “a catalogue of errors”, adding: “The tragic loss of this cheerful, resilient, beautiful, bright little angel is absolutely devastating for us all.”

Speaking after the inquest, Cristiana’s parents Alexandru and Georgina told the PA news agency that losing their daughter “in such a horrific way has left us feeling like we have no reason to wake up in the morning”.

“She was the apple of our eye and her avoidable death has left us beyond devastated,” they continued. “We never thought that by taking her to the hospital where she was born that she would never be coming home with us again.”

The family’s lawyer, Jodi Newton, a specialist medical negligence lawyer from Osbornes Law, added: “My clients’ world has fallen apart since losing Cristiana and they are struggling to understand how she could have been failed so fundamentally.”

She said the determination of Cristiana’s parents “to fight for answers is extraordinary”.

Alexandru and Georgina said the doctors and nurses responsible needed “to face some sort of justice” as without their mistakes “our daughter may well still be here today”.

“We need to know that this will never happen again as no family should ever have to go through the nightmare we have been through,” the pair added, ending an emotional statement.

PA contributed to this report