A girl who died from sepsis the week before her fifth birthday could have been saved if doctors at Nevill Hall Hospital had acted sooner, an inquest was told.
Skyla Whiting from Blaenavon became ill with an upset stomach on May 10, 2018, but assistant coroner Sarah Le-Fevre told Newport Coroner’s Court she died days later as a result of “inaction, late diagnosis and late administration of treatment”.
“Sepsis not only remained undiagnosed but unconsidered,” she said, when early treatment, including intravenous antibiotics, could have made a difference “on the balance of probability”.
The inquest heard that a diagnosis of possible septic shock was only made by a senior doctor on a ward round on May 14, the day after she had been re-admitted to Nevill Hall Hospital and several days after being seen by her GP.
Skyla was then taken to the University Hospital of Wales in Cardiff, but died a day later.
Recording a narrative conclusion, the coroner said a senior doctor at Nevill Hall should have been alerted sooner to the girl’s condition.
“There was a failure to recognise the nature and severity of Skyla’s illness,” she said.
“On the balance of probability Skyla would have survived with earlier intervention.”
Consultant paediatrician Dr Nadeem Syed told the inquest that Aneurin Bevan Health Board has since taken action to prevent such incidents happening again.
“Sepsis is not that common in children. However, sepsis is also one of the leading and most avoidable causes of death in the UK,” he said.
“In this particular case we failed to recognise the sickness of the child. Her mum’s concerns were not being looked in to.
“It was a failing to recognise and appreciate that a child is going through sepsis.”
He said that more training to recognise sepsis in children was now being provided and staffing levels had been improved.
An Aneurin Bevan University Health Board spokesperson 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.”
The inquest was told blood tests were delayed in the evening, and then a senior doctor wasn’t able to look at the results until later.
Because it wasn’t considered that Skyla had sepsis, she was not diagnosed or treated until next morning.
“There is no evidence at all that any thought was given to any possible diagnosis,” said Ms Le-Fevre.
The coroner concluded: “Skyla Whiting’s death from sepsis was contributed to by neglect in that, A: appropriate treatment was not administered between 11.30pm on May 13 and 1am on May 14, 2018, and B: no diagnosis of sepsis was made between 1am and 9am on May 14, 2018.”
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