«Breaking News» Series of hospital blunders and missed 'red flags' led to death of 15-month-old girl who had sepsis

A 15-month-old baby who died from sepsis was delayed in getting treatment after a catalogue of failings by medical professionals - a court heard.

Evie Crandle died on April 16, two days after she was taken to Whiston Hospital, by her concerned parents Samantha McNeice and Phil Crandle. 

The 15-month-old baby girl was sent home with ibuprofen and Calpol, Liverpool Coroner's Court heard on Tuesday, after medical professionals said she had a urine infection. 

A report carried out by St Helens and Knowsley NHS Foundation Trust revealed how there was a 'missed opportunity' in early sepsis diagnosis.

Evie was first brought to hospital by her devastated parents on April 14, at around 11.30am.

The couple told the court how their usually 'playful' daughter had been vomiting, was lethargic, had blue lips, cold hands and feet and a temperature of 39.9 degrees C - more than 2 degrees C over the average.

Two paediatric nurses - Kay Archer and Penny Hartley - failed to correctly fill in a sepsis pathway tool - a procedure in place to identify the killer disease.

The report, following an investigation, outlined how there was a delay in medical assessment of Evie, who was only seen more than three hours after she was seen in triage by Mrs Archer.

Evie Crandle, pictured, died on April 16 last year, two days after her parents - Samantha McNeice and Phil Crandle, pictured - took her to Whiston Hospital.

Further failings in recording observations, escalating her case to a senior doctor, communication between staff, administering antibiotics and carrying out blood tests were also outlined.

The court heard how the potentially life saving sepsis tool was only half filled in by Mrs Archer and not at all by Mrs Hartley. 

This meant that when Dr Jennifer Hale saw Evie before she was discharged, she only had Mrs Hartley's notes which had no suggestion of sepsis.

Yesterday Dr Hale told the court 'I didn't feel that she presented as a septic child, she was alert, drinking and interacting with her parents'.

No action was taken regarding the two factors that were outlined by Mrs Archer on the sepsis screening tool, on her first admission.

In evidence today, Dr Ijaz Ahmad told Liverpool Coroners Court how on Evie's return to hospital her symptoms were believed to be that of a 'severe kidney infection' and 'did not correlate' to that of sepsis.

The family's lawyer, Vanessa Cashman, told how Evie had a number of 'red flags' which were included on the sepsis pathway tool.

Parents Sam and Phil, from Whiston, told the court how they 'repeatedly asked about sepsis' but were 'let down in the worst possible way'.

And in court today Doctor Graeme Inkster said if the sepsis pathway had been followed Evie's case 'would have been escalated'.

On Monday, her devastated parents told an inquest how their 'beautiful' baby girl had been 'let down in the worst possible way' by medical staff.

In a heartbreaking statement Samantha, who is expecting her second child in six weeks' time, said she was 'broken beyond repair'.

Through tears, 31-year-old Ms McNeice told Liverpool Coroner's Court: 'Our lives were built around Evie. She was the centre of our universe.

'We have lost our daughter and have to face the fact we knew what was wrong with her.

'We took her to hospital straight away and asked over and over about sepsis. I remember saying 'are you sure this isn't sepsis?'

'I was petrified but stupidly allowed myself to take comfort from the fact that a medical professional was telling me 'it could be but it's most likely a urine infection'.

'I feel like I failed Evie in the worst possible way.

'We put all our trust in the medical staff and thought there was no way they would let our beautiful 15-month-old down.'

Liverpool Coroner's Court heard how Sam and Phil arrived at Whiston Hospital with their daughter at around 11.30am.

The couple told the court how their usually 'playful' daughter had been vomiting, was lethargic, had blue lips, cold hands and feet and a temperature of 39.9 degrees C - more than two degrees over normal body temperature.

Two paediatric nurses who saw Evie - Kay Archer and Penny Hartley - both told the court how they 'forgotten' to fill in sepsis documentation following their observations and had since had more training.

In medical notes taken by paediatric nurse Kay Archer, Evie's heart rate was recorded as 204 beats per minute - the average for a child of 15 months is 100 to 150. 

Meanwhile her breathing rate was 44 - the average is 25-35.

The court heard how both symptoms appear as flags on the medical septic screening tool guidelines.

Evie's parets were initially tld to take little Evie home and treat her with ibroprofun and Calpol. Paediatric nurse Penny Hartley told the court she 'forgot to fill in the sepsis tool in an oversight'

Mrs Kay told the court how she believed the symptoms Evie was presenting showed a 'possible water infection' and requested a urine sample be taken.

When asked by lawyer Vanessa Cashman, who is representing the family, did Mrs Archer remember the family asking her 'could this be sepsis?' she said 'I don't remember the family asking that'.

Mrs Archer was also asked why she did not fill out the sepsis pathway, on the triage forms.

Mrs Archer said: 'I regret not filling in that and since this incident I have had further training and I have learnt from my mistakes.

'Evie did not present to me as a seriously unwell child, she presented as unwell but not seriously unwell.

'My focus was on bringing down her temperature which can bring down the heart rate and respiratory rate.'

Evie was also seen and had observations taken by Paediatric nurse Penny Hartley, who told the court she 'forgot to fill in the sepsis tool in an oversight.'

Evie's mother Samantha, originally from Warrington, told the court how she and her partner were 'pretty well educated on sepsis ' and knew the signs and symptoms.

Partner Phil, from Whiston, added: 'We asked about sepsis straight away and even sat under a poster in the waiting room, but we were told its more likely a urine infection by a band 6 nurse and felt such relief despite still feeling such fear.

'They could never let a 15-month-old down. But they did.

Evie's mother Samantha said she was 'broken beyond repair' at the loss of her daughter 

'If I could go back knowing what I know now I would've screamed the place down until she was treated, but I can't and this fact fills my mind with guilt and regret. But what more could we do?

'We had told all professionals all of her symptoms and asked regularly 'is this sepsis?'

The court heard how the family were discharged at 4.30pm with ibuprofen and Calpol, but Evie's parents brought her back to hospital just two hours later because they were so concerned.

Dr Jennifer Hale saw Evie on her return to hospital, but despite there being two indicators on the septic screening tool, told the court 'I didn't feel that she presented as a septic child, she was alert, drinking and interacting with her parents'.

And it was only 15 hours later, following her first admission that Evie was given IV fluids, on the request of Dr Hale.

Evie died two days later at Alder Hey Children's Hospital, where she had been transferred following an admission into critical care.

Dr Hale told the court: 'I wasn't asked the question by her family if it could be sepsis. If I had it would have been an amber warning to me, if I had been asked that question.

'I have since had one to one training about sepsis, have completed a documentation course online and attended a sepsis summit.'

In a letter sent to Evie's parents, St Helens and Knowsley Hospitals Trust said it 'apologised sincerely that we did not meet the standards expected while Evie was under our care.

'I would like to assure you that by sharing the concerns raised during this process, practice has improved Trust-wide and lessons have been learned.' 

The inquest continues.

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Main photo article A 15-month-old baby who died from sepsis was delayed in getting treatment after a catalogue of failings by medical professionals – a court heard.
Evie Crandle died on April 16, two days after she was taken to Whiston Hospital, by her concerned parents Samantha McNeice and Phil...

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