A HOSPITAL made “a number of failures” in its care of a six-year-old girl before she died from sepsis, an inquest has heard.
However, there was no evidence to suggest that East Kent Hospitals University NHS Foundation Trust had directly caused or contributed to the death of the girl.
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Little Maya Siek, described as a “happy child”, tragically died at Queen Elizabeth The Queen Mother hospital in Margate, Kent, on December 21, 2022.
She had been sent home with antibiotics for suspected tonsillitis two days earlier, despite her mum insisting she was gravely unwell.
Her heart stopped beating after she suffered acute myocardial necrosis (death of the organ’s cells), which was triggered by sepsis.
Concluding an inquest into her death, coroner Catherine Wood identified a series of issues that “could have been done differently” by the trust.
This included a failure to keep Maya in the hospital on the night of December 19 and to inform all members of the treating team about her diagnosis of sepsis the following day.
“There were a number of failures at the trust in relation to Maya’s management,” Ms Wood told the inquest at Oakwood House in Maidstone.
“Generally, her condition didn’t appear to have been escalated as it should have been.”
Our life has been ruined, and our family will never be the same without her
Magda Wisniewska,
The inquest heard that Maya was a “well-looked-after little girl” who had “a lust for life, loved drawing, and was a happy child.”
She was taken to the A&E department at Queen Elizabeth The Queen Mother Hospital by her mother, Magda Wisniewska, on December 19 2022, after she collapsed.
Doctors determined she had possible tonsillitis and discharged her home with some antibiotics, but she collapsed on her way out of the department.
After further ECG and blood tests were taken, she was again sent home with advice to come back if she deteriorated, the inquest heard.
Ms Wood said she found the decision to discharge Maya that evening “inappropriate”.
Maya was brought back the following day after she had “gone downhill” overnight, at which point she was diagnosed with sepsis, and tests also showed influenza.
However, the inquest heard that nurses failed to document any real admission notes on December 20 about the diagnosis, but Ms Wood ruled that these were “non-causative failings”.
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There was also a failure to discuss sepsis guidelines with Ms Wisniewska and Maya’s father, Rajratan Bande.
Maya had been suffering from a persistently high heart rate throughout her time in the hospital.
Evidence also heard earlier in the inquest from doctors at Great Ormand Street revealed she also had other “chronic conditions”, namely problems with a fatty liver related to obesity and a thickened heart wall.
Ms Wood also identified the trust’s failure to adequately monitor Maya’s vital signs during her admission to the hospital’s Rainbow Ward and a failure to contact South Thames Retrieval Service for support.
The girl was given a dose of high-strength sodium chloride around 2am on December 21, but plans made for blood scans later that morning were not carried out.
Maya went into cardiac arrest later that day, and despite resuscitation efforts, she died.
The coroner accepted the cause of death as heart failure (acute myocardial necrosis), alongside the presence of Maya’s other chronic conditions and influenza.
Ms Wood said that “despite the plethora of evidence that we’ve heard, we still don’t really have the full answers” and was unsure if any earlier treatment by the trust “could or would have made a difference.”
In a statement given after the hearing, Ms Wisniewska said she has been “completely let down” by the hospital she had trusted to take care of Maya.
She said: “The trust did not fully appreciate what was wrong with her, and there were errors in treatment, which meant it was incomplete.
“Our life has been ruined, and our family will never be the same without her.”
“I do not want this to happen to other families and I only hope Maya’s death wakes doctors up to the signs of sepsis that they must be alert to.
“Unfortunately, it is too late for our daughter, but I hope that any changes that are made help save the lives of other children.”
What is sepsis?
From sweaty hands to a rash and even diarrhoea, sepsis can present itself in various different ways.
This is because the condition can affect many different areas of the body, so there are many possible symptoms.
Sepsis is life-threatening and can be difficult to spot, accounting for about 50,000 deaths each year in the UK.
It happens when the body attacks itself in reaction to an infection, like a urinary tract infection (UTI) or pneumonia.
It can lead to tissue damage, organ failure, and death.
Globally, one-third of people who develop sepsis die, according to the World Health Organisation (WHO).
And many who do survive are left with life-changing effects, such as post-traumatic stress disorder (PTSD), chronic pain and fatigue, organ dysfunction (organs don’t work properly), and amputations.
Like strokes or heart attacks, sepsis is a medical emergency that requires rapid diagnosis and treatment.
What are the symptoms of sepsis?
Symptoms of sepsis in an adult include:
- Acting confused, slurred speech or not making sense
- Blue, grey, pale or blotchy skin, lips or tongue – on brown or black skin, this may be easier to see on the palms of the hands or soles of the feet
- A rash that does not fade when you roll a glass over it, the same as meningitis
- Difficulty breathing, breathlessness or breathing very fast
Symptoms in a child include:
- Blue, grey, pale or blotchy skin, lips or tongue – on brown or black skin, this may be easier to see on the palms of the hands or soles of the feet
- A rash that does not fade when you roll a glass over it, the same as meningitis
- Difficulty breathing (you may notice grunting noises or their stomach sucking under their ribcage), breathlessness or breathing very fast
- A weak, high-pitched cry that’s not like their normal cry
- Not responding like they normally do, or not interested in feeding or normal activities
- Being sleepier than normal or having difficulty waking
They may not have all these symptoms.
Call 999 or go to A&E if they are suffering any of them.
Source: The NHS
Mr Bande told reporters he felt “disappointed” and urged medical professionals to “listen to the parents,” but he added that the coroner had done “a great job.”
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Dr Des Holden, the chief medical officer for East Kent hospitals, said the trust fully accepted the findings, adding: “We are truly sorry for the devastating loss of Maya, and we apologise unreservedly to Maya’s family for the mistakes we made in her care.
“We undertook a thorough investigation, facilitated by an experienced independent paediatrician … and we have made changes to our children’s service as a result.”