Critical chances were overlooked to preserve the life of a 13-year-old girl who requested to be put to rest due to ‘unbearable’ suffering before succumbing to sepsis in a medical facility.
Negligence on the part of NHS personnel played a role in the passing of Chloe Longster, from Market Harborough in Leicestershire, as determined by a coroner today.
Louise, her mother, brought her to A&E at Kettering General Hospital in Northamptonshire, due to ‘severe’ rib discomfort on November 28, 2022, following several days of cough and other mild flu-like indications.
As her state worsened, Chloe was swiftly moved to intensive care where she underwent intubation.
Chloe passed away the subsequent morning after spending 18-and-a-half hours in the hospital and receiving 30 minutes of CPR while in cardiac arrest.
Even with indications of sepsis, the necessary screening was postponed. It took almost eight hours after her arrival at the hospital for her blood pressure to be documented.
This would have raised a red flag for sepsis had it been conducted earlier, as noted by assistant coroner Sophie Lomas.
Initially, the doctors suspected Chloe suffered from a chest infection or pneumonia after a chest x-ray revealed solid material instead of air in her lower-left lung.
There were additional delays in the ordering and administering of appropriate antibiotics.
Rachel Young, the attorney for the Longster family, stated there was a ‘chain of delays’ and ‘crucial and significant missed opportunities’ in Chloe’s treatment.
She conveyed to the inquest: ‘The evidence is unmistakable – a sepsis screening did not occur when it should have.’
A nurse who failed to initiate the sepsis screening while recording observations could not explain her inaction but acknowledged that she should have, according to Ms. Lomas.
In a narrative verdict presented to the court, Ms. Lomas remarked: ‘Between 00.15 and 00.40 there were signs of septic shock. Recognizing that should have prompted immediate response.
‘There were multiple missed chances to acknowledge Chloe’s declining health. The trust has identified those shortcomings, admitting there were flaws in both medical and nursing care.’
‘I genuinely believe that had Chloe’s condition been recognized sooner, it would have been manageable and would have influenced the outcome.
Her demise was influenced by negligence. Numerous missed opportunities to detect and respond to her deteriorating state occurred.’
The hospital extended its apologies, while Chloe’s relatives condemned ‘a prevailing perception that parents are an annoyance.’
Louise Longster is tormented by the thought that ‘the 13-year-old was the one who was correct’, revealing to the inquest that Chloe queried her ‘if she was going to pass away.’
In a statement presented by Ms. Lomas during the inquest, Chloe’s family portrayed her as an ‘extraordinary individual’ who was ‘born into a family that cherished her deeply.’
They expressed: ‘She was an inspiring example to others with a heart of gold.
‘Chloe perceived the world through a lens of kindness. If only the world could have reciprocated that kindness. If only during her time of need she had encountered similar compassion.’
Mrs. Longster recounted how Chloe relished dancing and gymnastics, noting that aside from mild asthma, she was ‘very healthy’ and had previously never been hospitalized.
Prior to the five-day inquest, Mrs. Longster perceived herself as ‘powerless’ during Chloe’s hospital stay.
‘I was continuously going back and forth to obtain the medication Chloe required and had been prescribed,’ she shared.
‘It felt as though everything was unduly postponed, lacking any genuine urgency or initiative.
‘There was plenty of time, and numerous chances existed. She was literally within their view, and everything needed was right there.
‘I firmly believe Chloe passed away due to a prevailing mindset that parents are nuisances, which is fundamentally incorrect.
‘There has to be empathy and compassion when caring for particularly ill children. During that time, Chloe was unable to voice her needs. I felt entirely powerless, as did her father.’
Mrs. Longster described life as a ‘living nightmare’ following Chloe’s death.
She expressed: ‘Nothing can compare to the loss of a child. Chloe’s absence is profoundly felt – she was much larger than life in many aspects, exuding excitement and energy.’
After concluding the inquest on Friday, Mrs. Longster addressed the media, stating: ‘While nothing can restore Chloe, we appreciate the coroner’s acknowledgment of negligence in her narrative conclusion. There was a long list of missed opportunities in Chloe’s treatment.’
Julie Hogg, the chief nurse for the University Hospitals of Northamptonshire, extended her deepest sympathies to Chloe’s family for their loss. ‘We regret that we failed to provide the exceptional care Chloe deserved – we could have done more.’
‘Since Chloe’s passing two years ago, our teams have diligently worked to implement significant enhancements, particularly in managing patients with sepsis and those who aren’t improving.
‘We have also augmented our staffing levels and refined our communication with patients and their families. We realize there is still work ahead, but we are committed to ensuring every patient receives exemplary care.’
Ms. Lomas concluded the inquest by addressing the family, stating: ‘Chloe’s passing is profoundly tragic.
‘You have painted a portrait of a remarkable child who had much to contribute. I extend my condolences in light of that loss.’
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