Pin
Get email alerts
Request correction
Investigation and inquest
On the 6ᵗʰ December 2022, I commenced an investigation into the death of Meha Carneiro.
The investigation concluded at the end of the inquest on the 1ˢᵗ March 2024
The conclusion of the inquest was a narrative as follows:
Meha Carneiro died at 14.28 hours on the 5ᵗʰ December 2022 at the age of 5 years and 7 months, from cardio-respiratory collapse caused by infection with Group A streptococcus. Meha had Down syndrome. The seriousness of her clinical condition was not recognised when she presented to Kings Mill Hospital on 5.12.22 at 07.39 hours. She was managed with oral fluids, and struggled to have more than a very minimal intake, she had continuing diarrhoea, and was not reviewed by a paediatrician, nor a senior doctor in the Emergency Department, as she should have been. She was not provided with intravenous fluids nor antibiotics as she should have been.
The lack of repeated observations, the lack of review of the oral fluid challenge, the lack of senior review, leading to the lack of recognition of the seriousness of her condition, all probably made a more than minimal, negligible or trivial contribution to her death. Had intravenous fluids and antibiotics been provided in the morning of 5.12.22, she would on balance have survived.
Her death was contributed to by neglect
Circumstances of the death
Meha died at Kings Mill Hospital on 5.12.22. She had Down syndrome, and was unwell with intermittent fever, cough, abdominal pain and diarrhoea and vomiting over the two to three days prior. She was brought to hospital on the morning of 5.12.22 by her father, and collapsed in cardiac arrest approximately five and a half hours after admission. She could not be resuscitated.
Detailed findings as to how she came by her death are provided in a written Determination dated 1.3.24, appended to this report
.
Coroner’s concerns
1. There were insufficient trained Paediatric nurses on duty in the Emergency Department (ED), on the day of Meha’s admission, and there was no effective escalation to senior nursing staff to highlight this
2. There was overall a lack of recognition of how unwell Meha was on admission and over the subsequent hours prior to her death- this included both nursing and medical staff in ED
3. Whilst switching from use of POPS to PEWS in ED, is likely to assist in ensuring repeat observations in a sick child, a PEWS of 6-8 only triggers review by a junior rather than a senior ED Doctor, the former less likely to recognise severity of illness and respond appropriately
4. There was insufficient and ineffective handover between medical staff, with lack of documentation of key information, and agreed clinical plans- between doctors in ED, and between ED and Paediatric staff
I am not reassured that necessary actions to address these serious issues identified are in place.
Information checked against the published report and official responses