The conclusion of the inquest into the death of a four-year-old girl who died just hours after developing symptoms of meningococcal septicaemia, a form of sepsis, while waiting for a routine operation to have her tonsils removed was heard on Friday 14th September 2018.
Gracie Ella Foster, of Old Whittington, near Chesterfield, Derbyshire, died on 21 October 2015. She was booked into Chesterfield Royal Hospital on 21 October 2015 to have her chronically enlarged tonsils taken out due to them causing some difficulties with swallowing and speech.
Upon admission, Gracie was fine and chatting with the nurses as normal. However, while waiting for the surgery to take place, Gracie deteriorated suddenly, becoming very agitated, floppy and sleepy. The youngster also immediately vomited her pre-medication back up. A hospital nurse noticed that Gracie felt hot and recorded her temperature at 40.1 degrees. Gracie was taken back to the ward and was reviewed by the anaesthetist, who cancelled her operation.
The staff nurse requested that a paediatrician review Gracie. The locum consultant attended and confirmed Gracie did not need antibiotics and could go home. Gracie’s mum, Michelle Foster, carried her off the ward and she was home by 1pm. Gracie spent the afternoon with her grandmother while Michelle, believing her daughter had a viral infection from which she would fully recover, returned to work. Gracie continued to vomit throughout the afternoon and felt hot. She was unable to communicate with her father on the phone when he rang at about 6.45pm.
At 7pm, two non-blanching spots were found on Gracie’s body so her grandmother rushed her to Sheffield Children’s Hospital. By the time Gracie arrived at the hospital at 8pm, she was floppy, unresponsive and covered in a purpuric rash.
In spite of extensive attempts to resuscitate her Gracie could not be saved and she died a few hours later at 10.36pm after suffering two cardiac arrests.
Conclusion of the Inquest
Dr Robert Hunter, Senior Coroner for Derbyshire, recorded a narrative conclusion stating that Gracie died of natural causes contributed to by neglect.
“Nothing will bring Gracie back – her early, tragic and avoidable death is something from which her family will never recover. Gracie walked into hospital on the day of her death a happy, chatty and joyous little girl. She deteriorated suddenly becoming agitated, floppy and sleepy. In spite of this, Gracie was sent home from hospital with her family believing she would recover from what was just a routine viral illness.
“Gracie’s family never imagined that the very same day they would see their little girl covered in tubes, being resuscitated – witnessing Gracie’s death in such traumatic circumstances is something they have to re-live daily.
“The family hopes that what happened to Gracie will raise awareness and understanding of the devastating illness of meningococcal septicaemia, so that her death serves to lessen the chances of her tragic story being repeated.
“Meningococcal septicaemia is a poorly understood illness in terms of the symptoms to look out for, not only by the general public but also by the medical profession. They can be similar to those you may experience with a routine viral illness. However, it is well recognised that there are important red flag symptoms which set the illness apart from viral infection.
“The inquest revealed some extremely concerning evidence of Gracie being deprived of basic medical treatment during her time at Chesterfield Royal Hospital on 21 October 2015. The coroner identified systems failures within the hospital which were further compounded by the fact that basic vital signs were not undertaken and a clinical history was not performed. The seriousness of Gracie’s condition was underestimated, went undiagnosed and untreated. Had such treatment been provided, Gracie is likely to have survived.
“The coroner’s conclusion was that there were gross failures by the attending health care professionals and as such, Gracie died of natural causes, contributed to by neglect.
“The inquest also raised issues regarding Public Health England’s limitations when it comes to notifiable diseases such as the one Gracie had. Another child at Gracie’s school had been diagnosed with meningococcal disease just weeks before Gracie’s death. However, as Public Health England only notifies secondary health care providers when there has been an outbreak of such an illness, as opposed to a seemingly isolated case, Chesterfield Royal Hospital was not aware that Gracie may have come into contact with the disease.
“It is understood that the coroner will be writing to Public Health England expressing his concerns and asking them to review the policy in light of Gracie’s story. It is hoped this will prevent other families from having to suffer such heartbreak.”