Coroner says 'healthy' three year old's death would 'likely have been preventable'

A two-day inquest in Chelmsford has ruled that three-year-old Zadie Ajetunmobi's death 'could have been preventable'.

Zadie died at Broomfield Hospital Essex on 11 November 2022, after being admited to hospital with tonsillitis and a high temperature.

Within 10 hours she had gone into cardiac arrest and died.

Paediatric Consultant, Dr Arindam Das, admitted to 'serious failings', 'missed opportunities' and an unmet 'standard of care that is expected.'

Zadie's cause of death was pneumonia and bronchilitis.

Her post mortum noted she also had sepsis, but the failure to trigger Sepsis treatment, amongst other failings, is what the coroner said could have saved Zadie's life.

"Within an hour of arrival at the hospital, she should have been commenced upon and treated according to the Sepsis pathway. Had this occurred, her death would likely have been preventable."

"Her death would likely have been preventable"

The Mid and South Essex NHS Trust has formerly apologised and admitted failings, such as:

• Failure to assess the CEWT (children's early warning tool) correctly.

• A lack of review by a senior clinician

• A failure to recognise how sick Zadie was as nurses had said she was 'alert' and 'active'

• A failure to trigger Sepsis pathway

The coroner said the latter failure was by 'far and away the most significant shortcoming and contributory towards cause of death.'

Dr Das said in the Inquest the Sepsis guidelines at the time did not meet NICE (National Institute for Health and Care Excellence) Sepsis guidelines.

"The pathway we were using was not robust compared to the subsequent pathway which we have introduced from January 2023.

He also criticised the CEWT score, which is a weighted score that helps identify hospitalized children who might deteriorate .

"There is no scoring system UK or worldwide which is full proof. For example body temperature is not included. You need additional evidence.

"Each hospital is different but we are now using a more updated, and more robust framework.

"We have made it mandatory since the sad demise of Zadie that all children who attend A&E will have to be assessed using the Sepsis tool."

The coroner did not rule Zadie's case as 'neglect'.

Zadie's parents Theo and Rhiannon Ajetunmobi have said they are "grateful" to the Coroner for his "thorough and searching analysis of the issues surrounding Zadie's death.

"We are, of course, devastated to have heard very clearly that Zadie's death was avoidable."

"This is a tragedy from which we will never recover and which we hope no other parents ever have to endure.

"We urge Broomfield Hospital and those who were on duty that night to learn all necessary lessons from our terrible experience. The Inquest has confirmed that had the hospital’s sepsis guidance been applied, Zadie's symptoms would have triggered the sepsis pathway and she should have been given intravenous antibiotics within an hour.

"It is beyond painful to know that if Zadie had been given the intravenous antibiotics she would have survived.

"No apology, Coroner or NHS report can take away our heartache or bring our beautiful little girl back. But we hope the examination of the events surrounding Zadie's death helps to prevent future tragedies.

They've urged other parents to learn more about sepsis and be aware of the signs to raise concerns with medical professionals.

The Trust noted there had been "three further cases" which were "similar" but "nuanced" since Zadie's death.

However they added that they've already taken "a number of steps" to prevent similar tragedies from occurring.

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