Report says staff at Royal Cornwall hospital ‘lacked compassion’ after death of Coco Bradford

This article is more than 1 year old

This article is more than 1 year old

A six-year-old girl taken to hospital with stomach problems died after medical staff missed several chances to save her life, a highly critical independent report has concluded.

The Royal Cornwall Hospitals NHS trust accepted there were a series of failures in the care of Coco Rose Bradford, who died of sepsis.

Coco, who had autism, was not treated for dehydration, the report said, and there was a delay in giving her antibiotics when symptoms suggested she had sepsis.

The girl’s family said it was hard to live with the knowledge that Coco would probably still be alive if relatively straightforward treatments had been administered at the right time.

Sepsis: how parents and professionals can spot the symptoms Read more

Coco’s family spotted on 22 July 2017 that she was not eating well and over the next two days she began vomiting and having diarrhoea. In the early hours of 25 July her parents called an ambulance.

She was taken to the emergency department of the Royal Cornwall hospital (known as Treliske) exhibiting symptoms including vomiting, bloody loose stools, and an inability to tolerate fluids.

Coco was sent home but returned to the hospital near Truro the following day and was admitted to the paediatric ward, before being moved to adult intensive care. Her condition worsened and she died on 31 July 2017.

An independent report published on Friday said: “There were a number of missed opportunities throughout Coco’s care and treatment. The investigation team concluded that there were key points when, if her clinical management plan had been altered, the outcome for Coco could have been different.”

These included:

• It was not recognised that she was clinically dehydrated and in clinical shock on arrival at the emergency department on 26 July.

• Her clinical dehydration and clinical shock were not treated appropriately while she was on the paediatric ward.

• Her blood pressure was not obtained until 28 July at 12.15am, 36 hours after her admission to hospital.

• There was delay in starting antibiotics overnight on 27/28 July when her clinical picture suggested she had developed sepsis.

The report added: “A primary contributory factor was the inadequate staffing resources to manage the patient cohort.”

It also said that the way Coco’s family were dealt with by the trust after her death “at times lacked compassion and sensitivity”.

Hospital overcrowding blamed for rise in recorded sepsis deaths Read more

Coco’s mother, Rachel Bradford, said: “I am appalled by the level and magnitude of failings from the moment Coco entered Treliske on Tuesday 25 July. Our beautiful, little girl did not stand a chance.

“She was happy and healthy and absolutely loving life. She really loved learning, she loved the beach, swimming, eating chocolate and listening to music. She was at a mainstream school.

“I cannot and will not ever forgive those individuals we hold responsible for Coco’s death. They know who they are and they should be utterly ashamed of themselves.”

She claimed some staff accused Coco of being uncooperative and non-compliant, which she found “unforgivable”. Bradford added: “I would expect that rather than just learning from Coco’s death certain members of staff will be held accountable for it.

“It is very to live with, especially when you know all that Coco needed was rehydration, a simple course of intravenous fluids. That’s it, no miracle drug, no specialist treatment. The failure of treating the initial infection led to Coco contracting sepsis.

Cornish hospital says sorry after 'neglect' of woman who died Read more

“I will be forever thankful that I told Coco I loved her at least 10 times every single day and that the last words I ever heard Coco say on Thursday night, the 27 July were: ‘I love you’.”

After Coco’s death it was found she had an E.coli infection and haemolytic-uremic syndrome.

Kate Shields, the chief executive of Royal Cornwall Hospitals NHS trust, said: “The report describes a series of failures in care and missed opportunities to treat Coco at a time when her death could have been avoided and her symptoms treated.

“We have fully accepted the report’s findings and will report our progress against every one of its recommendations publicly. We accept and acknowledge the fact that for Coco and her family we were not good enough. We apologise unreservedly.”