The mother of 15-month-old Evie Crandle who died of sepsis last April wept in court today as the coroner recorded a verdict of death from natural causes contributed to by neglect.
Fifteen-month-old Evie Crandle died on April 16 2018, two days after her parents Samantha McNeice and Phil Crandle took her to Whiston Hospital, Merseyside.
Doctors at Whiston hospital failed twice to put Evie on a course of treatment which might have saved her and didn’t listen to her parents’ warnings that she was extremely ill until it was too late.
Samantha McNeice and Phil Crandle have slammed a Merseyside hospital after their daughter Evie died from sepsis two days after she was sent home with Calpol
Liverpool Coroner’s court heard that Evie died from multiple organ failure and severe invasive group A streptococcal infection after medical staff failed to spot her symptoms of sepsis.
Ms McNeice even told staff she feared her little girl had a blood infection, but a series of failures by staff meant the family were packed off home with medicine they could have bought at a supermarket – calpol and ibuprofen.
Yesterday assistant coroner Julie Goulding said Evie arrived at Whiston Hospital on April 14 after her parents became worried about her condition. Evie was lethargic and had been vomiting.
Ms Goulding said that a triage at Whiston should have been alerted to the possibility of sepsis due to Evie’s symptoms.
The court heard that Evie had a high temperature, and a fast heart and respiratory rate. Ms Goulding said that Evie should have been placed on the sepsis pathway at this point, a procedure in place to identify the killer disease.
However that did not happen.
Evie died despite her parents specifically raising their fears about sepsis to hospital staff
Ms Goulding said the failure to urgently administer fluids and antibiotics was a ‘missed opportunity’.
Evie, from Whiston, was sent home at around 4.30pm after she was given medicine to reduce her temperature. Staff suspected that she had a urinary infection.
But Evie’s parents brought her back to Whiston hospital just after 6.30pm because she was not getting better.
When Evie was re-admitted to hospital she had a heart rate of around 169, which should have led to a ‘review into her condition.’ Ms Goulding said that Evie needed antibiotics.
Again the coroner found that a blood test should have been carried out, and that antibiotics should have been administered. She said this was yet another opportunity to put her on the sepsis pathway.
The missed chances to save little Evie
11.30am, April 14 – Evie is brought to Whiston hospital. The coroner found that staff should have been alerted to the possibility of sepsis due to her high temperature and fast heart rate. She should have been placed on the ‘sepsis pathway’ and administered fluids and antibiotics.
4.30pm – Instead of being treated, Evie was sent home after being given medicine to reduce her temperature.
6.30pm – Evie’s parents brought her back to Whiston hospita again because she was not getting better. She now had a heart rate of around 169, which should have led to a review of her condition, a blood test and antibiotics, but instead her parents were again left waiting.
9.30pm – A doctor at Whiston administered an antibiotic cream, but Evie was not seen again by a doctor for another two hours.
2.45pm – More than 15 hours after Evie were first brought in, she is finally given her first full dose of antibiotics.
April 16 – Evie tragically dies after being transferred to Alder Hey Children’s Hospital.
At around 9.30pm a doctor at Whiston administered an antibiotic cream, but Evie was not seen again by a doctor for another two hours. At 2.45am in the morning Evie received her first full dose of antibiotics.
The coroner said that a consultant saw Evie at around 4am, but ‘failed to recognise how poorly she was.’
She was transferred to Alder Hey Children’s Hospital where she was treated in intensive care. Evie died the next day.
In summary the coroner said: ‘There had been a failure at the time to recognise how ill Evie was, a failure to complete the sepsis assessment tool and to place Evie on the sepsis pathway (twice) or for a senior doctor to say why it was appropriate to deviate from the pathway.
‘There were also failures to initiate appropriate treatment in a timely manner, to undertake appropriate observations of vital signs, to communicate effectively between staff and to complete fundamental documentation.
‘There were delays and failures to summon appropriate senior and consultant level assistance in a timely manner in addition to which Evie’s mother asked doctors if Evie could have sepsis, one of those times being at about 00.30 hrs on 15/04/2018 and at the time the doctors did not think it was, the working diagnosis being that of infection.
‘Insufficient notice was taken of Evie’s parents, not only did mum ask explicitly whether Evie could have sepsis but both parents expressed their concerns about her changed behaviour and how different she was from her usual bright, playful self.’
The coroner also said that St Helens and Knowsley NHS Foundation Trust had agreed to an action plan to prevent a future death of this type. She said that she had written to the trust to enquire how the action plan would be implemented.
A spokesperson St Helens and Knowsley Teaching Hospitals NHS Trust said: ‘The Trust offers its sincere condolences to Evie’s family for their devastating loss, and has unreservedly apologised for the shortfalls in her care.
Her devastated parents said of the youngster: ‘She was the centre of our universe’
‘When Evie first attended A&E it was not anticipated that her condition would deteriorate so seriously. Sepsis is a rare and difficult condition to diagnose with symptoms similar to those of many childhood illnesses.
‘Following Evie’s death, an immediate and thorough investigation was carried out. The Trust accepted that Evie’s care could have been improved and shared those finding with Evie’s parents.
‘Action plans have been implemented to ensure lessons have been learned.’
Evie’s mother slammed the hospital’s failures today after the coroner’s verdict that neglect had contributed to her death.
Ms McNeice told the BBC: ‘Although it was a relief that someone’s listening to you finally, and they’ve understood what happened wasn’t right, it was not nice to hear that she was so badly neglected.’
Assistant coroner Julie Goulding ruled: ‘If intravenous antibiotics has been given earlier, on balance, it was likely to have made a difference to the outcome.’
Earlier this week, Mr Crandle and Ms McNeice told an inquest how their ‘beautiful’ baby girl had been ‘let down in the worst possible way’ by medical staff.
Ms McNeice told Liverpool Coroner’s Court: ‘Our lives were built around Evie. She was the centre of our universe. We have lost our daughter and have to face the fact we knew what was wrong with her.
The NHS trust in charge of Whiston Hospital has apologised to the family after today’s ruling
‘We took her to hospital straight away and asked over and over about sepsis. I remember saying ‘are you sure this isn’t sepsis?’
‘I was petrified but stupidly allowed myself to take comfort from the fact that a medical professional was telling me ‘it could be but it’s most likely a urine infection’.
‘I feel like I failed Evie in the worst possible way. We put all our trust in the medical staff and thought there was no way they would let our beautiful 15-month-old down.’
After coroner Julie Goulding found 15 different failures at the hospital in connection with Evie’s death, Miss McNeice said NHS staff needed to be better prepared to listen to parents who know their children best.
Miss McNeice, 31, said: ‘We had seen the campaign. We were asking from the moment we got to the hospital if it was sepsis. We put our trust in the doctors and nurses and they let us and Evie down so badly.’
Mr Crandle, 35, added: ‘They didn’t listen to us.’
Ruling that Evie died of natural causes, ‘contributed to by neglect’, Miss Goulding said there was no doubt the failure of nurses to complete a ‘sepsis assessment tool’ meant Evie was denied the antibiotics which would have saved her.
After the hearing Evie’s parents, who are both operations managers at a children’s charity, described their daughter as a ‘perfect, wonderful little girl’.
Commenting on the Coroner’s verdict of neglect following Evie Crandle’s inquest, medical negligence lawyer Diane Rostron said:
‘Sam and Phil were very clear that their 15-month-old daughter Evie was showing signs of sepsis. They knew this as soon as they arrived at Whiston hospital and repeatedly alerted medical staff to this throughout that day. They have been failed by no less than six medical staff on the day and have unnecessarily lost their little girl.
‘The Trust’s internal investigation following Evie’s preventable death was flawed and found limited failings in the care provided. The Trust only revised their report into the incident after being challenged. It has been very disappointing and concerning that throughout the inquest the NHS staff still believed that they gave Evie the right level of care.
‘Evie was in the care of Whiston Hospital for no less than 16 hours. She was showing signs of sepsis at triage and should have been given antibiotics within one hour of admission in line with national guidelines which the Trust chose to ignore.
‘Evie Crandle could and should have been saved with a simple, and timely, course of antibiotics. The Trust failed to provide adequate levels of patient care and have since admitted liability for Evie’s avoidable death.’
The inquest has heard how the couple took their usually ‘playful’ daughter Evie to the hospital after she had been vomiting, had blue lips, cold hands and feet and a temperature of 39.9C.
Two paediatric nurses who saw Evie – Kay Archer and Penny Hartley – both told the court how they had ‘forgotten’ to fill in sepsis documentation following their observations and had since had more training.
A report into the death found there was a delay in medical assessment of Evie, who was only seen more than three hours after she was seen in triage by Mrs Archer.
Further failings in recording observations, escalating her case to a senior doctor, communication between staff, administering antibiotics and carrying out blood tests were also outlined.
The court heard how the potentially life saving sepsis tool was only half filled in by Mrs Archer and not at all by Mrs Hartley.
This meant that when Dr Jennifer Hale saw Evie before she was discharged, she only had Mrs Hartley’s notes which had no suggestion of sepsis.
Dr Hale told the court ‘I didn’t feel that she presented as a septic child, she was alert, drinking and interacting with her parents’.