'Missed opportunities' and staff neglect contributed to 4-year-old Skyla Whiting's sepsis death
A four-year-old girl died from sepsis after neglect by medics who sent her home from hospital with the virus, an inquest has heard.
Skyla Whiting, from Blaenavon in Pontypool, died just days before her fifth birthday in May 2018.
On January 28 this year, Newport Coroners' Court heard that there were a number of "missed opportunities" by medical staff which contributed to her death.
The inquest also heard that low staffing levels at the hospital led to a lack of immediate senior intervention.
Speaking after the inquest, a spokesman for Aneurin Bevan University Health Board said their thoughts were with Skyla's family and that they have already taken measures to address the issues raised by their investigation.
Skyla fell ill with a fever, high temperature and elevated heart rate on May 10, 2018 and was taken to Nevill Hall Hospital in Abergavenny two days later, after being seen by a GP.
Doctors at the hospital diagnosed Skyla with a viral infection but her parents remained concerned and she was readmitted the following day as she was vomiting and had a large rash.
On the evening of May 13, doctors who saw Skyla did not consider she might have Sepsis but decided to do blood tests at around 8:30pm. It was not until 10:30pm that the test were carried out, with the results available an hour later.
The coroner heard that doctors did not end up seeing the results for around another hour.
It was not until 9am the following morning, when a senior consultant attended the ward, that they recognised Skyla was suffering from septic shock.
The four-year-old was moved to University Hospital of Wales in Cardiff and put into the intensive care unit. She died there on May 15, just over a week before her fifth birthday.
A medical cause of death was given as sepsis resulting from lower respiratory tract infection, the inquest heard.
Sarah Le-Fevre, assistant coroner for Gwent, said that there were "missed opportunities" to prevent Skyla's death, adding that the evidence suggested earlier intervention may have led to a different outcome.The inquest heard the findings of a report compiled in part by Dr Nadeem Syed from Aneurin Bevan University Health Board. The report highlighted a failure among hospital doctors to realise the severity of Skyla's condition.
Dr Syed, a paediatric consultant, explained that although Sepsis is one of the leading avoidable causes of death in children in the UK, it is not very common in young people so "it would not be in the everyday dealings of paediatric staff".
Dr Syed added: "However, this was a failure to recognise the sick child with sepsis and the severity of their illness. The child was not thought to be seriously unwell – that is why it was not escalated."
He also said that they were concerns over the hospital not "appropriately" listening to Skyla's mother, Amy, when they re-attended the hospital.
The inquest also heard that low staffing levels at the hospital led to a lack of immediate senior intervention.
The senior consultant on shift at the time was available until 1am but was then summoned to tend to another seriously ill patient an hour later. They first saw Skyla at 9am on May 14 and recognised the severity of her condition.
Dr Syed told the hearing that while there were "decreased staff levels" there was also "an expectation of decreased patient attendance".
He added that the incident had been taken "very seriously".
"Different layers are being put in place to improve the safety of the child so that future incidents do not happen," he said."Sepsis awareness is part of the induction taken by every doctor and junior doctor."
In summing up, Ms Le-Fevre said that there was a "failure to recognise the severity of Skyla's condition" and that, based on evidence submitted to her, on the balance of probabilities, the child's death could have been avoided had she received appropriate treatment and a quicker diagnosis.She added that a conclusion of natural causes was not appropriate and instead found that neglect did contribute to Skyla's death. Ms Le-Fevre expressed her "sincerest condolences" to Skyla's family.Speaking after the inquest, a spokesman for Aneurin Bevan University Health Board said: “Our thoughts remain with the family of Skyla and we’re very sorry for the circumstances surrounding the care she received.
"This matter has been fully investigated by the health board in accordance with its Serious Incident protocol.
"The findings have been fully and openly shared with the family and the senior coroner for Gwent.
"The health board has already undertaken actions to address the issues raised through our investigation, with a strong emphasis on the importance of recognising the symptoms of deteriorating sepsis patients.”