Neglect by NHS staff contributed to death of girl, 13, from sepsis

Opportunities were missed to save the life of a 13-year-old girl who asked to be put to sleep due to ‘unbearable’ pain before dying of sepsis in hospital.

Negligence by NHS staff contributed to the death of Chloe Longster, from Market Harborough in Leicestershire, a coroner concluded today.

Her mother Louise had taken her to A&E at Kettering General Hospital, Northamptonshire, with ‘severe’ rib pain on November 28, 2022, after a few days of a cough and other mild cold-like symptoms.

With her condition deteriorating, Chloe was soon transferred to intensive care where she was intubated

Chloe died the following morning after 18-and-a-half hours in hospital and 30 minutes of CPR while she was in cardiac arrest.

Despite signs she had sepsis, a screening was delayed. It took nearly eight hours from arriving at the hospital for her blood pressure to be recorded.

This would have triggered a red flag for sepsis had it been done sooner, assistant coroner Sophie Lomas said.

Instead, doctors initially believed Chloe had a chest infection or pneumonia after a chest x-ray showed solid material, rather than air, in her lower left lung.

There were further delays in the prescription and administering of the correct antibiotics.

Rachel Young, the Longster family’s solicitor, said there were a ‘sequence of delays’ and ‘crucial and significant missed opportunities’ in Chloe’s care.

She told the inquest: ‘The evidence is clear – a sepsis screening did not happen when it should have taken place.’

A nurse who did not start the sepsis screening when she recorded observations could not articulate why she did not, but she agreed she should have, Ms Lomas said.

In a narrative verdict read to the court, Ms Lomas said: ‘Between 00.15 and 00.40 there were signs of septic shock. Recognition of that should have prompted immediate action.

‘There were several missed opportunities to recognise Chloe’s deteriorating condition. The trust recognised those missed opportunities, they have stated there were shortcomings in care both medically and in nursing.”

‘I do accept on balance that Chloe’s condition, if identified earlier, could have been managed and would have altered the outcome.

‘Her death was contributed to by negligence. There were repeated missed opportunities to recognise and respond to her deteriorating condition.’

The hospital has apologised, while Chloe’s family blamed ‘a pervasive belief that parents are an irritant’.

Louise Longster is haunted ‘that the 13-year-old was the one that was right’, telling the inquest that Chloe asked her ‘if she was going to die’.

In a statement read by Ms Lomas to the inquest, Chloe’s family described her as an ‘exceptional human being’ who was ‘born to a family that loved her so very deeply’.

They said: ‘She was a shining example to others with a heart of gold.

‘She saw the world through a lens of kindness. If only the world could have been kinder back. If only in her time of need she was shown the same compassion.’

Mrs Longster said Chloe enjoyed dancing and gymnastics, and was ‘very healthy’ aside from having mild asthma, and had never been admitted to hospital before.

Speaking before the five-day inquest began, Mrs Longster said she felt ‘powerless’ while Chloe was in hospital.

‘I was up and down constantly trying to get Chloe the medication that she needed and she was prescribed’, she said.

‘Everything just felt really delayed, there didn’t seem to be any sort of meaningful urgency or action.

‘There was ample time, there were plenty of opportunities. She was literally under their noses and everything was there.

‘I really believe Chloe died because there is a pervasive belief that parents are an irritant and they’re wrong.

‘There needs to be empathy and compassion when dealing with especially sick children. Chloe was voiceless for that period of time. I was completely powerless, as was her dad.’

Mrs Longster said life has been a ‘living nightmare’ since Chloe passed away.

She said: ‘Nothing compares to losing a child. Chloe’s absence is deafening – she was larger than life in a lot of ways, she was very much just excitable and a burst of energy.”

Following the conclusion of the inquest on Friday, Mrs Longster said in a statement: ‘While nothing can make up for the loss of Chloe, we are pleased with the coroner’s findings of neglect as part of her narrative conclusion. There was a catalogue of missed opportunities in Chloe’s care.’

Group chief nurse for the University Hospitals of Northamptonshire, Julie Hogg, said: ‘We offer our deepest condolences to Chloe’s family for their loss. We are sorry that we failed to offer Chloe the care she deserved – we should have done more.

‘In the two years since Chloe died our teams have worked hard to make significant improvements, including our management of patients with sepsis and those who are not getting better.

‘We have also increased our staffing levels and improved the way we communicate with our patients and their families. We realise there is still more to do but we are committed to ensuring that every patient receives the best care.’

Ms Lomas concluded the inquest by addressing the family and said: ‘Chloe’s loss is tragic.

‘You, through the pen portrait, presented a picture of a wonderful child who had so much to give. I pass on my condolences in respect of that.’

Get in touch with our news team by emailing us at webnews@metro.co.uk.

For more stories like this, check our news page.