Selina Samarina · Prevention of Future Deaths report

On 11ᵗʰ April 2023, I commenced an investigation into the death of Selina Samarina, aged 2. The investigation concluded at the end of the inquest on 28ᵗʰ May 2024. The conclusion of the inquest was that the deceased died of natural causes, the medical cause of death being that she had died from sepsis and pneumonia, with contributory factors of Down’s Syndrome and Upper Respiratory Tract infection. She died in Broomfield Hospital

Selina had been brought into hospital by her parents with symptoms of fever, a rash and irritability. She was made an urgent referral and the sepsis protocol/ procedure was triggered. That should ordinarily lead to an examination by a senior doctor within an hour. In this case, a very junior doctor was sent over, in part because there was huge demand on the ward services and the available doctors of seniority were otherwise engaged with other patients. Selina’s diagnosis was thus arrived at by a relatively junior doctor, and other possible diagnoses such as sepsis or pneumonia were not addressed.There was no differential diagnosis.
It was not until two and a half hours later that a doctor of appropriate seniority was available to assess Selina, by which time, as was consistent with the directions from the junior doctor, Selina had gone home with her parents. Evidence was given by the consultant that on that particular day, a Bank Holiday (Good Friday), there would normally be 12 doctors across the Emergency Department and Paediatrics Department, but on that day, there were only 7. This increased workload and the demand for services (which was at a normal level) had played a part in the consultant not being available to review Selina’s condition within the timescale mandated by the sepsis protocol,

(1) I was told in evidence that the Trust has now consolidated the staffing rotas for the Emergency Department and Paediatrics Department, so that it is now easier to see any deficit as one deficit across two departments. That does not however, address the situation of how and why a situation in which only 60% of the doctors are available for these important services.
(2) I am concerned about the overall sufficiency of the staffing arrangements.