A Hospital Trust has admitted being at fault for the death of a three-year-old girl after failing to act upon symptoms of septicaemia when she was suffering from chickenpox.
Despite rapidly worsening symptoms, including a raised temperature, increased heart rate and pains and swelling to her left foot, doctors at Newham Urgent Care Centre, London failed, to recognise Blessing Matia’s life was in immediate danger.
A day after being sent home from the hospital’s Urgent Care Centre with pain-killers for her foot, Blessing had a cardiac arrest at home and stopped breathing.
Emergency services were unable to resuscitate her and she died just a week after first showing signs of a rash from chickenpox.
Subsequent investigations have since revealed she had suffered a streptococcal infection as a complication of chicken pox which is ‘extremely rare’.
It was concluded that doctors should have acted quicker to the symptoms and prescribed antibiotics to tackle the blood infection, which would have saved her life.
Symptoms of sepsis wrongly overlooked as chicken pox
Blessing, from East London, had first been taken to the Urgent Care Centre by her parents Alex Kasota and Miesi Ziamo, with a raised temperature of 38 degrees and swelling around her eyes on June 2, 2015. She was also found to have a raised heartbeat.
Her elder brother, Bright, eight, had recently had chicken pox and she’d had a rash appear on her body over the previous three days, with her parents treating her with calpol. It was noted by a nurse at the surgery on that first visit that she had chicken pox and a possible secondary infection.
However, despite Miss Ziamo telling an inquest she was at the centre from 2pm, a full GP examination didn’t take place as she still had not been seen by 5pm, when the mother had to leave as her elder son needed collecting from school.
That night, with their daughter continuing to have a fever, the parents called 111 in the early hours to be told to give her calpol and nurofen and to call their GP in the morning. The GP said Blessing’s fever would still be being caused by the chickenpox
The following day, on June 4, with her left foot and ankle swollen, the family returned to the Urgent Care Centre where an x-ray was carried out on Blessing’s foot, which showed no bone injuries.
The diagnosis remained chickenpox and after three hours at the centre she was sent home at 7.30pm with paracetamol. Her parents were told to keep her leg raised and to see a GP again within five days.
However, in the early hours of the following morning, Blessing woke up and was unable to walk on her leg. Over breakfast she was confused, asking to go home although she already was home, before she became unresponsive.
Miss Ziamo called an ambulance, picked Blessing up and ran to a neighbours for help, but their efforts, and those of paramedics when they arrived, were in vain.
East London NHS Foundation Trust, which ran Newham Urgent Care Centre at the time, has now admitted being responsible for the toddler’s death after a case was brought against it on behalf of the family by medical negligence experts Hudgell Solicitors.
Independent evidence, gathered as part of the legal case, concluded that Blessing would have been saved had doctors prescribed antibiotics on any of the occasions her family sought medical help.
Number of failings identified and danger signs missed
A Serious Incident Review also identified a number of failings in care, firstly in that doctors didn’t contact Miss Ziamo to call her back with Blessing for examination when she was forced to leave to collect her son from school.
It also criticised doctors in that three recognised danger signs (fever, increased heart rate and swollen limbs) were not explored more comprehensively the day before she died.
Sue Jackson, the solicitor who represented the family, said:
This is an extremely sad and tragic case of a little girl whose life could and should have been saved.
Our independent evidence concluded that with a reasonable standard of care Blessing would have survived. Any reasonably competent doctor caring for children in any way should be aware of this complication.
He concluded that with appropriate treatment, namely the prescription of antibiotics on either of the visits to the health centre, she would have made a full recovery and would not have had any long term complications.
Clear failings were also highlighted in the Serious Incident Review, firstly in that concerns over possible infections were not fully investigated when Miss Ziamo first attended at the centre, and that a number of concerning symptoms were ignored.
Blessing should still be here today with her family and would have now started out on her life’s journey by being at school. She would have recently celebrated her fifth birthday.
We handle many cases of medical negligence and very few highlight so clearly the devastating cost of simple and avoidable mistakes being made.
Dr Shirley Radcliffe, Assistant Coroner for the Eastern Area of Greater London, said that the administration of antibiotics on June 4 ‘would have resulted in prevention of this death’.
The cause of death was recorded as Group A Streptococcal Septicaemia from chickenpox.
The Serious Incident Review recommended the Trust, develop new quality standards for waiting times of children at the Urgent Care Centre.
It also recommended a revision of protocol for managing situations where children leave the centre before completion of treatment and the development of a new process for health visitor reviews of under-5s who attend at the centre.
Other recommendations included requiring all children presenting with a temperature above 38.5°C to be seen in the Emergency Department instead of the Urgent Care Centre.