Catalogue of failures at Manchester hospital contributed to disabled girl’s death
BMJ 2012; 345 doi: https://doi.org/10.1136/bmj.e5387 (Published 08 August 2012) Cite this as: BMJ 2012;345:e5387A coroner has ruled that a hospital contributed to the death of a disabled 12 year old girl who was admitted with flu-like symptoms by a catalogue of failures in diagnosis and treatment.
Emma Stones, who had cerebral palsy and an estimated mental age of 5, died of septicaemia at Tameside Hospital in Greater Manchester in February 2011 after delays in diagnosis and treatment of a bacterial infection.
The inquest was told that a junior doctor wanted to take a blood sample but that a senior registrar was “too busy” to help. A team of three nurses failed to monitor Emma regularly through the night, although she should have been observed every four hours, and her blood pressure was never taken.
When she was found dead in her bed, her body was so stiff and cold that the nurse who found her had difficulty removing her hand from the bed rail. The coroner said it was “simply not acceptable” that her father should find her in that state, although he was told she had just died.
“If the observations had been performed more accurately, and the treatment had been instigated at an earlier stage, the likelihood is that Emma would have survived,” he added.
“Emma was not monitored properly or at all in the hours before her death, and when her father held her she was cold and stiff. Mr Stones was understandably concerned that he was told his daughter had died at 8.50 am, when she was cold by nine o’clock,” said the coroner.
“From 5 am onwards there is every reason to believe that, sadly, Emma had already died. I’m quite satisfied that the nursing and medical care of Emma at Tameside General Hospital fell below the standard that most people would consider satisfactory.”
Emma’s father, Mike Stones, said, “We are grateful for the coroner’s verdict. As far as we are concerned this was neglect of the worst kind. How can NHS staff be so neglectful of any sick child, leave alone a girl with a mental age of 5? There must be lessons learnt from this, and people need to be held to account.”
Peter Walsh from the patient safety charity Action against Medical Accidents, which arranged for the family to be represented at the inquest, said, “This is not the first inquest into hospital deaths which we have been involved in which has identified substandard levels of care.
“Whilst most NHS care is excellent, something needs to be done to address problems with a lack of communication, coordination, and basic care which blights a small but significant strand of the service and leads to these scandalous tragedies. That’s the least the family deserve.”
The hospital acknowledged that “the standard of care which we gave Emma was not acceptable.”
Notes
Cite this as: BMJ 2012;345:e5387
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