Hospital "profoundly regrets" failings in care following St Ives girl's death
A coroner ruled Coco Rose Bradford died from a rare blood condition, not sepsis
Last updated 15th Jan 2022
The Medical Director of the Royal Cornwall Hospitals' Trust says they "profoundly regret" the failings in care received by a little girl from St Ives, following the inquest into her death.
A statement from Dr Allister Grant said "we entirely accept" the coroner's conclusions, including that six-year-old Coco Rose Bradford died from a rare blood condition, not sepsis.
Coco, who had autism, was rushed to Treliske back in July 2017 with severe diarrhoea and vomiting.
The six-year-old was transferred to Bristol Children's Hospital, where she died three days later.
In 2018, an independent review found multiple opportunities were missed to treat her for sepsis at the Royal Cornwall Hospital.
However on Friday, a coroner ruled Coco died from Haemolytic Uraemic Syndrome (HUS) caused by an E.coli infection, not sepsis.
'We regret Coco's family has been caused additional distress'
The coroner, Mr Andrew Cox, said it was "deeply regrettable" the family had been "misled".
He agreed with evidence of "basic failings" in Coco's care, such as the fact her blood pressure was not taken until 36 hours after she was admitted, "sub-optimal" fluid management and a delay in escalating her care to intensive care staff at Treliske, despite the fact a consultant had discussed transferring her to an intensive care unit Bristol.
However Mr Cox found her tragic death could not have been avoided, saying she was "something of a hostage to fortune".
The RCHT said that following an independent investigation into her death, an action plan had been "fully implemented" and the inquest's conclusions would be reviewed to "identify any further learning".
'We let Coco and her family down'
Dr Allister Grant said: "Today the Coroner has provided his conclusions following an inquest into the death of six year old Coco Bradford. We entirely accept his conclusions and profoundly regret the failings in the care Coco received.
"While the coroner has concluded, based on the expert evidence, that different treatment would not have avoided Coco’s tragic death, this does not take away from the fact that we let Coco and her family down. This is a matter of deep sorrow to those who cared for Coco, as was acknowledged during the inquest.
"We also regret Coco's family has been caused additional distress by the belief that Coco's poorly condition was explained by sepsis, as opposed to an overwhelming inflammatory condition called HUS (Haemolytic Uraemic Syndrome). We note the coroner has concluded on the evidence presented during the Inquest that Coco did in fact not have sepsis.
"The quality and safety of the care received by each and every patient is our highest priority.
"Following an independent investigation into her death a detailed action plan has been fully implemented and we will now ensure we review the coroner's conclusions with great care to identify any further learning that can improve the provision of care to children, including those with learning difficulties".
In a statement Coco's family said they needed more time to come to terms with what happened, adding: "We will never come to terms with life without Coco in it".