Neglect played role in death of Blaenavon girl from sepsis

Skyla Whiting fell ill with an upset stomach on May 10, 2018. Two days later, she was taken to Abergavenny's Nevill Hall Hospital. She showed signs of improvement and was discharged, only to be readmitted on May 13.

There, her condition worsened, and she died of sepsis at University of Wales Hospital in Cardiff on May 15, just a week before her fifth birthday.

An inquest into her death was resumed at Newport Coroner’s Court on Friday, having been adjourned in November.

Dr Nadeem Syed, a consultant paediatrician at Aneurin Bevan University Health Board and co-author of the serious incident report into Skyla’s death, told the court that staff at Nevill Hall failed to recognise Skyla had developed sepsis.

“Sepsis is not that common in children. However, sepsis is also one of the leading and most avoidable causes of death in the UK,” he said.

“In this particular case we failed to recognise the sickness of the child. Her mum’s concerns were not being looked in to.

“It was a failing to recognise and appreciate that a child is going through sepsis."

“Had that [sepsis treatment] commenced earlier, the outcome would, on the balance of probability, have been different,” said Sarah Le Fevre, assistant coroner for Gwent, when summing up evidence heard in November.

The court heard that a decision was made to take blood tests from Skyla at around 8.30pm on May 13, but due to a “series of events” this wasn’t done until around 10.30pm. The results became available about an hour later, but a senior doctor was not free to view these until around 12.15am.

In cases of suspected sepsis, treatment is administered before blood test results come back, the court heard.

However, it wasn’t considered that Skyla had sepsis, and so she was not treated for that until, at around 9am, following a face-to-face ward round, a senior consultant recognised she was suffering septic shock.

Ms Le Fevre said there was a missed opportunity to provide care to Skyla, and there was a delay in diagnosing sepsis.

“There is no evidence at all that any thought was given to any possible diagnosis [of sepsis],” she said.

Dr Syed said the staffing levels at Nevill Hall were “quite different” to the staffing levels now, with the two paediatric teams across Nevill Hall and the Royal Gwent now brought together at the Grange University Hospital.

“The idea is to make sure a senior practitioner is available 24/7,” he said.

“The evidence shows that if there is a senior clinician, the mortality rate is less in a child with sepsis. They have more experienced hands and might have seen sepsis more compared to a junior doctor, who might not recognise the signs of sepsis.”

Helen Morgan, a divisional nurse and transformation manager at the health board, who also co-authored the report, said all new starters were now trained on the PEWS charts – which offer guidance on monitoring a child’s status when in hospital – and that this training was audited every year.

Concluding, Ms Le Fevre said: “Skyla Whiting’s death from sepsis was contributed to by neglect in that, A: appropriate treatment was not administered between 11.30pm on May 13 and 1am on May 14, 2018, and B: no diagnosis of sepsis was made between 1am and 9am on May 14, 2018.”

Ms Le Fevre confirmed Skyla’s medical cause of death was sepsis and lower respiratory tract infection.

A spokesman for Aneurin Bevan University Health Board said: “Our thoughts remain with the family of Skyla and we’re very sorry for the circumstances surrounding the care she received. 

“This matter has been fully investigated by the health board in accordance with its Serious Incident protocol.

“The findings have been fully and openly shared with the family and the senior coroner for Gwent.

“The health board has already undertaken actions to address the issues raised through our investigation, with a strong emphasis on the importance of recognising the symptoms of deteriorating sepsis patients.”