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Investigation and inquest
On 30th October 2024, Alison Mutch OBE, Senior Coroner for Greater Manchester (South) opened an inquest into the death of Lila Airelle Marsland who died at home on 28th December 2023, aged 5 years. The investigation concluded with an inquest which was heard between 27th May to 5th June 2025 before a jury.
A post mortem examination determined Lila died as a consequence of Pneumococcal Meningitis (Streptococcus Pneumoniae).
At the end of the inquest, the jury returned the following Narrative Conclusion:
‘Lila Airelle Marsland died as a consequence of undiagnosed and therefore untreated Pneumococcal Meningitis (Streptococcus Pneumoniae) a number of hours following her discharge from hospital. Lila’s death was contributed to by neglect.’
Circumstances of the death
Lila Marsland was brought to Tameside General Hospital on 27th December 2023, having become unwell that day with symptoms of headache, fever, lethargy and neck pain. Following interaction over the hours which followed with a range of healthcare professionals, Lila was discharged home with a diagnosis of viral tonsillitis and a prescription of oral antibiotics and a throat spray. Lila was found to have died around six and a half hours after her discharge from hospital.
Coroner’s concerns
To the Chief Executive, Tameside and Glossop Integrated Care NHS Foundation Trust
1. Having carefully considered the oral evidence given in court by a range of different clinicians with varying roles and remits, I am concerned that, notwithstanding the work the Trust has undertaken in response to Lila’s death, the Child Sepsis Screening Tool is not yet fully embedded in the minds of those who assess and treat Children and Young People at the Trust;
2. I am concerned that the Trust is yet to fully implement the latest iteration of the National Institute of Health and Care Excellence’s Guideline Meningitis (bacterial) and meningococcal disease: recognition, diagnosis and management (NG240 Published 19 March 2024);
3. It is a matter of concern that the Locum Consultant in Emergency Medicine who completed a form indicating Lila was ‘Safe to Transfer’ to the Paediatric Emergency Department did so without undertaking any examination or direct assessment of her. The doctor had previously filed a statement at court indicating he had undertaken a ‘preliminary visual assessment’ of Lila, but accepted in oral evidence that this was not, in fact, the case;
4. I am concerned that no medical record appears to exist of the examination of Lila which was undertaken by the Locum Registrar in Paediatrics which resulted in Lila being discharged from hospital. The absence of this key piece of evidence serves to limit the ability of the Trust to derive all possible learning from Lila’s death.
To the Secretary of State for Health and Social Care
The court heard evidence that, over the course of almost 10 hours in hospital, Lila’s history and details of examinations and assessments undertaken were recorded on a mixture of various analogue and digital systems in operation in different parts of the Trust, leading to a risk of vital clinical information being lost in the system.
I am concerned that this, and other hospitals elsewhere in the country, continue to operate with information being stored and shared between professionals in a fragmented and disjointed way.
Information checked against the published report and official responses