Kent NHS trust failed in care of young girl before death
Coroner Catherine Wood identified a series of issues that "could have been done differently"
There were "a number of failures" at a Kent NHS trust in its care of a six-year-old girl before she died, an inquest has found.
However, there was no evidence to suggest that trust had directly caused or contributed to the death of the girl.
Maya Siek died at Queen Elizabeth The Queen Mother hospital in Margate, Kent, on December 21 2022, having been sent home with antibiotics for suspected tonsillitis two days earlier.
The hospital is run by East Kent Hospitals University NHS Foundation Trust.
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 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."
The inquest heard how 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.
"Inappropriate"
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".
There was also a failure to discuss sepsis guidelines with Ms Wisniewska and Maya's father, Rajratan Bande.
Maya had been suffering with a persistently high heart rate throughout her time in 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 given 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.
Heart failure
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 added she 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."
Mr Bande told reporters he felt "disappointed" and urged medical professionals to "listen to the parents", but added that the coroner had done "a great job".