Cornwall inquest overturns sepsis finding in girl's death

A six-year-old girl thought to have died from sepsis was in fact suffering from a blood condition triggered by an E.coli infection, an inquest has found.

Coco Rose Bradford died on 31 July 2017 at the Bristol Royal Hospital for Children after being transferred from the Royal Cornwall Hospital (RCH).

Coroner Dr Andrew Cox, sitting in Truro, said it was "deeply regrettable" that the family had been misled.

The RCH trust said it "profoundly" regretted "failings" in care.

Coco's death was the subject of an independent review published in autumn 2018, which found opportunities had been missed to treat sepsis and was critical of the care given by staff at Treliske.

Specifically, doctors were criticised for failing to administer antibiotics sooner.

But Dr Cox found that Coco, from St Ives in Cornwall, had died from multiple organ failure caused by the rare haemolytic uraemic syndrome (HUS), caused by toxins given off by E.coli infection.

The inquest heard Coco's family felt staff at the RCH were "dismissive, rude and arrogant" and did not take her condition seriously.

There were also failings in care such as her blood pressure not being taken until 36 hours after she was admitted, and "sub-optimal" fluid management.

Dr Allister Grant, the RCH Trust's medical director, said while it had been shown different treatment would not have avoided Coco's "tragic death", that "does not take away from the fact that we let Coco and her family down".

He said: "This is a matter of deep sorrow to those who cared for Coco, as was acknowledged during the inquest."

Following an independent investigation into her death a detailed action plan was implemented and the coroner's conclusions would be used to improve the care to children, he said.

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