‘Gross failures’ at King’s Mill contributed to little girl’s death, says coroner
MEHA, 5, HAD DOWN’S SYNDROME, PUTTING HER AT GREATER RISK
A FIVE-YEAR-OLD girl’s death from strep A was contributed to by “gross failures” at a Nottinghamshire hospital, an inquest has found.
A coroner said staff at King’s Mill Hospital failed to recognise the severity of Meha Carneiro’s condition before she died on December 5, 2022.
“Earlier intervention would, on the balance of probabilities, have prevented her death,” said assistant coroner Elizabeth Didcock, finding neglect had contributed to her death. Concluding the inquest at Nottingham Council House on Friday, she said medics should have given “greater attention” to the fact Meha had Down’s syndrome, which gave her a greater risk of dying from the bacterial infection.
“The omissions in her care are serious, very serious, and are gross failures,” added Ms Didcock.
Meha’s parents, from Sutton-inashfield, said the death was “unbearable”.
Elvis and Dalcy Carneiro said: “Meha was the most adorable girl and we felt blessed she was our daughter. Despite the challenges she faced she was such a happy little girl who brought sunshine to our lives.
“It’s almost impossible to find the words to describe the hurt we feel over Meha’s death. The hurt we feel and the hole her death has left in our family is unbearable.
“When we took Meha to hospital we were worried but never thought it would lead to the chain of events that happened and she would never return home.” Meha was taken to the emergency department at King’s Mill by her father at 7.39am after she had been unwell for three days. Following a triage assessment 20 minutes later, Meha was moved to the paediatric area and put on an oral fluid challenge – a way of getting fluids into a child to prevent them becoming dehydrated. But Meha’s vital signs were not checked again, despite a heart rate of 177bpm, and her fluid chart was not properly assessed. She went into cardiac arrest at around 1.50pm and died 40 minutes later.
“I find that the lack of repeated observations and the lack of review of her fluid challenge, leading to the lack of a senior medical review more than minimally contributed to her death,” said Ms Didcock.
The coroner also said an initial paediatric observation priority score (POPS) should have been recorded as higher, which would have led to a paediatric early warning scoring tool (PEWS) being used. “This should led to Meha being moved to the resus area and being reviewed,” she said. “They all had a clear and direct cause. Had she been treated earlier in the morning, when the seriousness of her condition was evident, it is likely she would have survived.”
Staff at the emergency department were dealing with an “unexpected increase” of children at the time, which was largely due to the high number of strep A and flu cases.
Meha’s parents said a doctor at one point advised them to take their daughter home. They said: “He said it was the season for colds and viruses and there were too many patients in the department.”
NHS data read out to the inquest showed that just under 600,000 under-16s attended A&E departments across the country in December 2022 – over 100,000 more than in December 2021 and 2023. Sherwood Forest Hospitals, which operates King’s Mill, asked the busyness of the department to be considered as a mitigating factor.
However, Ms Didcock said she did not “accept that this is a valid factor given the severity of the failings”. She did however acknowledge “many changes” had been implemented at the hospital since Meha’s death.
Phil Bolton, chief nurse at Sherwood Forest Hospitals, said: “We welcome the level of scrutiny that this inquest has brought and will carefully consider the coroner’s findings to learn what lessons we can and ensure that we improve and provide the best possible care to our patients in the future.
“We would like to express our deepest condolences to Meha’s family for their loss and offer them an unreserved apology.”
It’s almost impossible to find the words to describe the hurt we feel over Meha’s death.
Elvis and Dalcy Carneiro