A coroner has returned a narrative verdict at an inquest into the death of a nine-month-old girl who died the day after being admitted to Birmingham Children’s Hospital.
The inquest into the death of Sada Hamza took place at Birmingham Coroner’s Court yesterday, presided over by Coroner Louise Hunt, just days after bosses at the hospital had admitted civil liability, in writing to the family’s solicitors, Shoosmiths.
The coroner said Sada’s death was ‘contributed to by a lack of intervention’ and that it was ‘likely’ the cardiac arrest would have been avoided had there been earlier intervention.
Her mother, Sakar Hussein, said after the inquest:
‘The trust has already admitted liability for its mistakes and we hope lessons are learnt from this so another family does not have to go through what we have gone through. This has been a tragic loss for my family, particularly my other children.’
Solicitor Amy Greaves represented Sada’s family throughout. She said:
‘The hospital has conducted an investigation into this case and has identified a number of failures resulting in Sada’s unnecessary and tragic death. This has been reinforced at the inquest by the coroner’s findings. We now hope steps will be taken to make sure such deaths don’t occur in the future.’
Problems began in July 2017, when Sada had been unwell for around 10 days. Her mother had noticed how she had not been settling and was constantly crying, both of which were unusual.
Then, on 29 July 2017, Sakar noticed her daughter’s breathing appeared to be unusual and she was breathing very quickly. Sada was admitted to Birmingham Children’s Hospital and was initially diagnosed and treated for a blood infection. She was kept in hospital overnight and monitored. She did not improve and her diagnosis was changed to suspected respiratory infection.
Throughout the next day (30 July 2017), Sada’s breathing continued to deteriorate. Sakar was extremely concerned about her daughter’s condition and was concerned that, despite being seen by a doctor a few times, Sada did not receive the treatment she required. Such was Sakar’s concern that she videoed her daughter’s deterioration. She also voiced her concerns with the staff monitoring Sada. She was advised Sada’s observations were normal and she did not need to be concerned.
At around 5pm, Sada was given oxygen which resulted in a temporary improvement in Sada’s condition. However, this was only provided for 10 minutes and Sada deteriorated when this stopped.
At around 8pm, Sada significantly deteriorated. She was in respiratory distress and went into cardiac arrest. She was successfully resuscitated and transferred to ITU. Sada had suffered significant brain injury and her life support was withdrawn on 1 August 2017.
Following Sada’s death a post mortem report concluded she had an undiagnosed cardiac problem that was not treated.
The hospital carried out a root cause analysis following Sada’s death. The investigation found two issues which resulted in a failure to recognise how ill Sada was.
The first of these was a complex failure to recognise how unwell Sada was, based on her mother’s history of Sada’s symptoms, which were potentially indicative of a cardiac problem. Once the treating staff had concluded Sada had a respiratory infection, any evidence to the contrary was ignored by the treating team.
The second issue was a failure in the PEWS (Paediatric Early Warning System). This is a scoring system used to monitor a patient’s condition whilst they are in hospital. Observations on the PEWS system were not monitored as standard meaning Sada’s condition was potentially under represented. Additionally, when the PEWS score did rise to a level that would have required escalation, this escalation did not happen.
The investigation report also highlighted other issues around:
- Poor documentation in the medical and nursing notes
- Recommendations for treatment made by doctor without having seen the patient
- Escalation points were reached, but escalation did not happen
- Failure to check Sada’s blood pressure (or document it) which is a critical component of the PEWS system and the score for these recording usually triggers escalation
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