Inquest into death of teen from sepsis at Kettering General concludes

An inquest into the death of a girl who died from sepsis at Kettering General Hospital has found there were 'missed opportunities' and a 'series of shortcomings' at the NHS trust.

Chloe Longster from Market Harborough died a day after arriving at Kettering General Hospital back on November 28th 2022.

Her mother Louise has previously said her daughter was "incredibly healthy" apart from having mild asthma.

After suffering a cold she got worse after coming home from school, with the family told to take her to A&E. She was admitted to the children’s ward before being intubated and taken to intensive care next morning.

Louise has stated it felt as if she was a nuisance when they were told to go to A&E.

The hospital believed the worsening condition was pneumonia, and she says that in her last 18 hours Chloe was treated with contempt.

The hearing has been hearing that checks that might have alerted doctors to sepsis were not carried out.

Outcomes were ruled that there was 'neglect with clear red flags being missed’ by Kettering General Hospital.

Louise Longster says lessons must be learnt, and things need to change:

"To listen to parents when they're worried about their children, and to listen to children when they're in pain.

"People don't go to hospital for fun."

She died shortly before 7am after going into cardiac arrest, following intubation in the intensive care unit.

Delivering her verdict, Coroner Sophie Lomas said there were “several missed opportunities” to recognise Chloe’s deteriorating condition and complete a sepsis screening at an earlier point.

First, she pointed to a missed opportunity at 6pm to implement a sepsis treatment pathway. Coroner Lomas also said that the decision to transfer Chloe to the Skylark Ward during the nurse handover was a “significant contributing factor” in the events that followed.

She said there was a further missed opportunity at around 11pm to undertake another sepsis screening which would have, on balance, triggered implementation of the sepsis treatment pathway.

She also said there were missed opportunities to use the appropriate antibiotic indicated in the sepsis treatment pathway instead of the broad-spectrum one Chloe was given.

She told the court that it was “likely on balance that had this antibiotic been given and given earlier” it would’ve been “more likely than not that she would have survived”.

She said there was a “clear causal link” between the issues she raised and Chloe’s death but added that it was not possible to say with certainty what the outcome would have been if different action had been taken.

Coroner Lomas ruled that the missed opportunities in this case amounted to neglect, which she described as a ‘gross failure’ to provide basic medical attention for someone in a dependent position.

She said the medical cause of death, in her view, was multiple organ failure, sepsis and pneumonia.

Giving evidence today (Friday, October 11), Coroner Lomas read out a written statement from Dr Naveed Alam who was on shift as a consultant paediatrician on the emergency department on the day Chloe was admitted. She said the inquest had anticipated to hear from him during the week, but they were unable to secure his attendance.

He said he saw Chloe at around 6pm and that her Paediatric Early Warning Score (PEWS) was a five at the time of assessment. A score above five could indicate a medium risk and recommends that sepsis be considered.

Coroner Lomas also read to the court a statement provided by the family: “Chloe was sunshine, she brought warmth and light into life and brightened any mood.

“A shining example to others with a heart of gold and the biggest grin. She exuded a sense of fun. Her excitement for life was contagious, especially when it came to celebrating with loved ones.

“From a young age, Chloe had been a dedicated dancer. Performing in shows and as the curtains closed on one she eagerly anticipated the next.

“She could always find fun and joy in the ordinary moments of daily life. With her magnetic personality, making friends was easy and keeping friends even easier.

“Chloe was the embodiment of kindness and was the champion of all things good. Losing her has caused the most pain I’ve ever felt.

“Reflecting on Chloe’s tremendous loss is devastating. She won’t sit her exams, learn to drive, travel with friends or go to concerts.

“Her whole future has been extinguished. We haven’t just lost Chloe, the whole world has lost her too.

“She deserves to be remembered for her colourful life rather than its conclusion. We will forever hold her in our hearts.”

Julie Hogg, the Group Chief Nurse for the University Hospitals of Northamptonshire, said: “We offer our deepest condolences to Chloe’s family for their loss. We are sorry that we failed to offer Chloe the care she deserved – we should have done more.

“In the two years since Chloe died our teams have worked hard to make significant improvements, including our management of patients with sepsis and those who are not getting better.

“We have also increased our staffing levels and improved the way we communicate with our patients and their families. We realise there is still more to do but we are committed to ensuring that every patient receives the best care.”

Speaking outside the court, Chloe’s mum said: “The pain of losing Chloe will never go away. She was the best of us, a lover of life but will no longer be able to experience it.

“We are pleased with the coroner’s finding of neglect as part of her narrative conclusion there was a catalogue of missed opportunities on care following Chloe’s admission to hospital.

“Both mine and Chloe’s grave concerns were either ignored or not taken seriously. Staff failed to identify that Chloe was in serious need of medical attention and no escalation was made that could’ve saved her life.

“Too many families have been through this heartbreak and needless tragedy. It’s been excruciating this week listening to their disagreement on fact.

“Justice for Chloe is having her true experience finally heard, acknowledged and that no child will ever have to suffer again in the way that she did. She should’ve been safe.

“I think nationally sepsis needs to be taken more seriously. For Chloe’s situation, everything was there, and I’m not sure what else was needed to save her life.

“Listen to parents when they’re worried about their children and listen to children that are in pain.”

Coroners didn't release a prevention of future death report, as changes had already been made directly in relation to Chloe's death.

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