Neglect by NHS staff contributed to 13-year-old’s sepsis death, coroner rules

Neglect by NHS staff contributed to the death of a 13-year-old girl in “unbearable” pain from sepsis in hospital, a coroner has concluded.

At an inquest which concluded at Northampton Coroner’s Court on Friday, assistant coroner Sophie Lomas said there were several key missed opportunities to save Chloe Longster’s life.

The missed opportunities identified in the inquest include delays to her sepsis screening and treatment, and delays to prescribe and administer the correct antibiotics.

Chloe, from Market Harborough in Leicestershire, was taken by her mother to the emergency department of Kettering General Hospital in Northamptonshire on November 28 2022 with “severe” pain in her ribs.

She had been suffering with a cough and other mild cold-like symptoms in the few days prior to her death, but the illness “didn’t interrupt her usual activities”, Chloe’s mother said.

In hospital, her condition deteriorated and she was later transferred from the paediatric ward, Skylark, to the intensive care unit (ICU), where she was intubated and she died the following morning after around 30 minutes of CPR while she was in cardiac arrest.

Chloe’s mother, Louise Longster, said her daughter “asked to be put to sleep” in the hospital because the pain was “unbearable”.

Mrs Longster told the inquest on the first day of evidence: “Chloe asked me on Skylark if she was going to die. It’s haunting that the 13-year-old was the one that was right. It’s devastating.”

Chloe’s chest x-ray showed “consolidation” to the lower left lung, where there is solid material rather than air, which made doctors initially believe that she had a chest infection or pneumonia.

The family’s solicitor, Rachel Young, made submissions to the coroner, including that a “sequence of delays” and “crucial and significant missed opportunities” were present in Chloe’s care.

She added: “The evidence is clear – a sepsis screening did not happen when it should have taken place.”

In a narrative verdict read to the court, Ms Lomas said: “Between 00.15 and 00.40 there were signs of septic shock. Recognition of that should have prompted immediate action.

“There were several missed opportunities to recognise Chloe’s deteriorating condition. The trust recognised those missed opportunities, they have stated there were shortcomings in care both medically and in nursing.”

“I do accept on balance that Chloe’s condition, if identified earlier, could have been managed and would have altered the outcome.

“Her death was contributed to by neglect. There were repeated missed opportunities to recognise and respond to her deteriorating condition.”

Chloe’s blood pressure was recorded for the first time on the system nearly eight hours after she arrived at the hospital.

Ms Lomas said that had the blood pressure been recorded earlier, her Paediatric Early Warning Score (PEWS) would have triggered a red flag for sepsis.

A nurse who later recorded observations did not start the sepsis screening tool and could not articulate why she did not, but agreed that she should have done, Ms Lomas told the inquest.

In a pen portrait from Chloe’s family which was read to the inquest, they said she was an “exceptional human being” who was “born to a family that loved her so very deeply”.

The statement, read by Ms Lomas, said: “She was a shining example to others with a heart of gold.

“She saw the world through a lens of kindness. If only the world could have been kinder back. If only in her time of need she was shown the same compassion.”

Mrs Longster said Chloe enjoyed dancing and doing gymnastics, was “very healthy” aside from having mild asthma, and had never been admitted to hospital before.

Speaking before the five-day inquest began, Mrs Longster told the PA news agency she felt “powerless” in the 18-and-a-half hours Chloe was in hospital.

“I was up and down constantly trying to get Chloe the medication that she needed and she was prescribed”, she said. “Everything just felt really delayed, there didn’t seem to be any sort of meaningful urgency or action.

“There was ample time, there were plenty of opportunities. She was literally under their noses and everything was there.

“I really believe Chloe died because there is a pervasive belief that parents are an irritant and they’re wrong.

“There needs to be empathy and compassion when dealing with especially sick children. Chloe was voiceless for that period of time. I was completely powerless, as was her dad.”

Mrs Longster said life has been a “living nightmare” since Chloe passed away.

“Nothing compares to losing a child. Chloe’s absence is deafening – she was larger than life in a lot of ways, she was very much just excitable and a burst of energy.”

Following the conclusion of the inquest on Friday, Mrs Longster said in a statement: “While nothing can make up for the loss of Chloe, we are pleased with the coroner’s findings of neglect as part of her narrative conclusion. There was a catalogue of missed opportunities in Chloe’s care.”

Group chief nurse for the University Hospitals of Northamptonshire, Julie Hogg, said: “We offer our deepest condolences to Chloe’s family for their loss. We are sorry that we failed to offer Chloe the care she deserved – we should have done more.

“In the two years since Chloe died our teams have worked hard to make significant improvements, including our management of patients with sepsis and those who are not getting better.

“We have also increased our staffing levels and improved the way we communicate with our patients and their families. We realise there is still more to do but we are committed to ensuring that every patient receives the best care.”

Ms Lomas concluded the inquest by addressing the family and said: “Chloe’s loss is tragic. You, through the pen portrait, presented a picture of a wonderful child who had so much to give. I pass on my condolences in respect of that.”