lack of consideration and information at a hospital contributed to the dying of a two-year-old woman who had a uncommon response to influenza, an inquest has discovered.
A coroner dominated that Cristiana Banciu would most likely have had a greater probability of survival had she been transferred sooner to intensive care.
She was round a month shy of her third birthday when she died on January 8 2020 at King’s Faculty Hospital in Denmark Hill south London.
Cristiana had been transferred from the Princess Royal College Hospital (PRUH) in Orpington two days earlier on January 6.
The inquest at South London Coroner’s Court docket heard that she had been highlighted as a affected person of concern “a number of occasions” on the PRUH.
The inquest was informed that an investigation by King’s Faculty Hospital NHS Basis Belief discovered there was a failure to adequately monitor Cristiana on the ward, a failure to detect her declining neurological situation, and to behave and escalate on her low Glasgow Coma Rating (GCS).
Assistant coroner Jacqueline Devonish stated the failure to document Cristiana’s GCS was “very critical certainly”.
She stated: “It appeared to me that there was an absence of consideration and a lack of information which had instantly contributed to this little woman’s dying.”
Ms Devonish stated she is of the view that healthcare professionals “failed to supply fundamental medical consideration”.
She stated these have been “very fundamental neurological observations that wanted to be undertaken” and people outcomes correctly reviewed by a senior clinician.
“For my part that’s a gross failure,” she stated.
However she stated the legislation doesn’t help a discovering of neglect as a result of there is no such thing as a proof that Cristiana would have survived had she been handled sooner.
The tragic lack of this cheerful, resilient, stunning, brilliant little angel is totally devastating for us all
In her narrative conclusion, Ms Devonish stated: “Child Cristiana died from a uncommon response to influenza in circumstances the place the decline in her responsiveness, Glasgow Coma Rating (GCS) of 8, and progressively sluggish pupils had not been recognised.
“There was a consequential delay in switch to the paediatric intensive care unit.
“It isn’t doable to say on the stability of chances whether or not she would have survived if transferred sooner.
“However she would, most likely, have had a greater probability.”
Addressing the household, Ms Devonish stated: “I’ve seen the image of child Cristiana in your T-shirt. She’s completely stunning.
“And it’s an especially unhappy case. I do know that the household recognised early on that there was one thing significantly mistaken, and it’s a pity that these treating her didn’t additionally recognise that.”
She stated there had been “a listing of errors”, including: “The tragic lack of this cheerful, resilient, stunning, brilliant little angel is totally devastating for us all.”
Wherever Cristiana went, she lit up the room along with her smile and she or he made folks blissful
Talking after the inquest, Cristiana’s dad and mom Alexandru and Georgina stated: “Dropping our daughter in such a horrific manner has left us feeling like we have now no purpose to get up within the morning.
“She was the apple of our eye and her avoidable dying has left us past devastated.
“Wherever Cristiana went, she lit up the room along with her smile and she or he made folks blissful.
“We by no means thought that by taking her to the hospital the place she was born that she would by no means be coming residence with us once more.
“The medical doctors and nurses who failed her have to face some type of justice as with out their errors our daughter might effectively nonetheless be right here immediately.
“We have to know that this can by no means occur once more as no household ought to ever need to undergo the nightmare we have now been by way of.”
Jodi Newton, a specialist medical negligence lawyer from Osbornes Regulation, who represents the household, stated: “My purchasers’ world has fallen aside since dropping Cristiana and they’re struggling to know how she might have been failed so basically.”
She stated the willpower of Cristiana’s dad and mom “to struggle for solutions is extraordinary”.
The inquest heard the dad and mom travelled with their daughter within the ambulance to King’s Faculty Hospital and Mr Banciu stated that was the primary time he had been informed of the “actual scenario” she was in.
Mrs Banciu stated that on arrival at King’s Faculty Hospital the employees “did all they might” however that they have been informed their daughter had a lower than 0.1% probability of survival.