Hospital admits ‘series of failures’ led to 6-year-old’s sepsis death
Hospital chiefs have admitted a catalog of mistakes which led to the tragic death of a 6-year-old girl from sepsis.
Coco Bradford died on July 31, 2017, days after doctors at the Royal Cornwall Hospital assured the family she was "fine."
Members of the board of Royal Cornwall Hospitals NHS Trust (RCHT) accepted an independent report into the death of Coco, from St. Ives, on Friday.
They faced damning statements from Coco’s family, who described how they were treated with arrogance by staff on Polkerris Ward.
Luke and Rachel Bradford described how staff failed to listen to them as their daughter lay dying.
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Coco died of sepsis, which she contracted at the Cornwall hospital, after being transferred to Bristol Children’s Hospital for treatment.
Medics in Cornwall assured the family that Coco, who was autistic, was OK, but mistakes were made in diagnosis and treatment.
The report, which included 13 recommendations to change procedures at the hospital, said mistakes were made in diagnosis and there was a delay in treating Coco.
It concluded: “There were numerous missed opportunities which we believe would have significantly increased her chances of survival.”
Attending the meeting in Truro were Coco’s parents, Luke and Rachel, and sisters Chelsea Elcocks and Bianca Ackroyd.
The room was shown a video of Coco, and board members were visibly upset and moved by the poignant images.
“After reading the final report into Coco‘s death in full, which has been extremely distressing and actually a further burden to bear, I am appalled by the level and magnitude of failings from the moment Coco entered Treliske on Tuesday, 25th July," Rachel Bradford said. "Our beautiful, little girl did not stand a chance. In July last year, Coco was living her best life ever. She was happy and healthy and absolutely loving life."
"She loved learning - really, really loved learning - she loved the beach, swimming, eating chocolate and listening to music, all the time, especially Justin Bieber and Little Mix," she said. “Then Coco became ill and, due to the multiple failings by certain members of staff in this hospital, she died eight days later and she never got to live the life she so deserves."
“Coco was an inspiration to others, a life changer, and she would definitely have grown up to be a world changer," she said. "She amazed us every single day. 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."
“To then, later, find out that they blamed Coco, her autism and from being uncooperative and non-compliant to excuse their own incompetence is unforgivable," she said. "For the record Coco was neither uncooperative or non-compliant. I am extremely angry regarding the questionable honesty of some clinicians and their failure to recall information even though it was documented."
"We questioned their actions constantly, begged for pain relief for Coco and Chelsea (Coco’s sister and a clinical skills tutor who has worked in ICU for over two years) questioned them directly by phone," she said. “They treated us with indignance and arrogance and told us they were not worried about Coco and she was fine, but actually she wasn’t. She was dying in front of our eyes."
She went on to explain how when "faced with a severely dehydrated child with diarrhea and vomiting," doctors decided not to follow guidelines.
She added: "when a clinician who agrees a plan for a dying child does not implement that plan or transfer to another hospital, and when a pediatric consultant does not recall, can’t remember, wasn’t aware of and cannot explain a course of action or procedures, it would seem acceptable to question the suitability of their chosen professions.”
“Coco’s death has had a devastating effect on us all," Bradford said. "She was absolutely the most precious person in our family and, for me, she was and continues to be the absolute love of my life. I cannot come to terms with her death and it has broken me mentally, physically and emotionally. I simply cannot put into words how losing Coco has made me feel."
"I spent nearly every day with her for 6 and half years, loving her, caring for her, protecting her and fighting for her. She meant and still means the world to me," she said. “When you take your child into [the] hospital you have to put your trust in the hands of the medical professionals if you, yourself, are not medically trained.
"You have to believe they are doing the best for your child. You really don’t have a choice," she said. “This report is not a full account of what really happened and what was actually said, as it would be classed as circumstantial or hearsay, but it most definitely confirms our worst fears and concerns from last July and that is very difficult 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, just intravenous fluids," she said. "The failure of treating that initial infection led to Coco contracting sepsis, which is what she actually died off.”
Coco’s sister, Chelsea, said Coco, known by her nickname "Coco-bean," was an adorable 6-year-old girl.
She described her bedtime routine and explained how Coco, who, because, of her autism, had been delayed in developing speech, would say "ruff you" for "I love you."
She said: “It’s Wednesday, July 26, 2017, and I’m sat looking at the same beautiful bleached blonde 6-year-old but this time she’s not well, so unwell she can barely lift her hand from the sofa where she lives. Sunken eyes, pale skin, dry mouth and can barely talk," she said. “I’ve already instructed my mum to call an ambulance and there is just time to say goodbye to little Coco-bean. This time I say, ‘Look at you little Coco-bean. You’ll get better soon. I love you.’"
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"She manages, somehow, to gather the strength to slightly lift her head and say, ‘Ruff you’. This is the last thing my beautiful little sister ever said to me. Just two days later and now I’m questioning staff at Treliske hospital. I’m angry because what I am telling them is not getting through," she said. "This is my expanded NHS family, people that, as a fellow health care professional, I should trust. I try, but they tell me they are not worried about this, no she doesn’t need that, and no we don’t use that system here."
“Even more infuriating is when I find myself sat in a room 12 months later, with the medical director telling me you were right all along, your instinct was correct from the offset," she said. “I am now furious that I allowed such incompetent health care professionals to create a smokescreen as to what was really happening, which is that no-one knew what the hell they were doing.”
She added: “Treliske at first were in denial and dishonest to us. I can forgive that. What I cannot forgive is that everything I have told you today could have and should have been avoided. My beautiful little sister could still be here today and we would never have had to stand here, falling apart, explaining how our lives have been impacted and are now ruined. The countless missed opportunities by fellow NHS staff mean I will never hear my little sister laugh, giggle or say ‘I ruff you’ again.”
Chairing the meeting was RCHT non-executive director Sarah Pryce, who said to the family: “I know I speak for the whole board in saying we are so very sorry.”
“None of us can possibly imagine what you have been through and continue to go through," she said. "Today, you’ve given us some indication into how special and a beautiful girl Coco was and some sense of the impact of your loss. It’s incredibly difficult to hear about your loss and pain but as a board, we are pleased to listen to you. To be honest, I am struggling to find words that are big enough to say sorry. We will learn from what happened to Coco. I know that doesn’t make your loss any less painful.”
Kate Shields, the chief executive of RCHT, also read a statement in which she said: “We have today formally received an independent report into the care and treatment of Coco Rose Bradford. We have fully accepted the report’s findings and will report our progress against every one of its recommendations publicly at our trust board."
“Coco was a 6-year-old little girl who was in our care on two occasions in July 2017," the statement said. "On the first occasion she was reviewed in the emergency department and sent home and on the second occasion, she was on one of our pediatric wards for three days. Coco was transferred from RCHT to Bristol Children’s Hospital on 28th July, 2017, where she died on 31st July, 2017."
“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," the statement said. "We know that Coco’s family and, in particular, Rachel, Luke, Chelsea and Bianca, have fought to get the full facts of the case. We will continue to work with them to try to fully understand why we failed and to make sure that Coco’s legacy for all children in Cornwall is - that this never happens again. The whole hospital trust and our communities in Cornwall will be saddened when they read the report."
"The care described is not read reflective of general care on our children’s wards," the statement said. "We have sought, and will continue to seek, external scrutiny of our services so that local people can be confident that we are safe and effective in the care of children in Cornwall. It is however vital that we accept and acknowledge the fact that for Coco and her family we were not good enough. We apologize unreservedly.”