Hospital neglect a factor in girl’s meningitis death

The death of five-year-old girl who was sent home from hospital with suspected tonsillitis hours before dying from meningitis was contributed to by neglect, an inquest jury has concluded.

Lila Marsland was examined by various medics over several hours at Tameside Hospital in Ashton-under-Lyne, Tameside, on 27 December 2023.

But despite displaying warning signs of meningitis no-one began the treatment which could have saved her life, Manchester South Coroner’s Court heard.

Her mother Rachael Mincherton said lessons must be learned from her death. The trust which runs the hospital said it “accepts the findings and apologises unreservedly”.

Ms Mincherton, of Hyde, Greater Manchester, described her daughter as “a lively and vibrant little girl” who was thriving at school and enjoying time with her friends.

She took her to the hospital’s A&E after finding her lethargic, with a headache and a worryingly fast heartbeat, the inquest heard.

The mother, who was a nurse at the same hospital at the time, said she queried whether Lila could have meningitis.

The jury heard her neck was so stiff and painful that various clinicians over several hours were unable to complete a standard test which would have pointed towards meningitis.

Another test on her legs should have raised warning signs but failed to do so and medical staff thought she had tonsillitis, the court was told.

About nine hours after she had arrived, Lila was discharged from the observation ward and sent home with her mother.

Just over seven hours after that she was pronounced dead by paramedics after her mother woke to find her unresponsive.

Expert witness Dr Philip Chetcuti previously told the court had Lila been given intravenous antibiotics in the first three hours of her time there, she would probably have survived.

The inquest heard Lila was never fully examined for a rash – only her chest and back – and the test on her neck was never fully carried out, partly because each person assumed that someone else had already done it.

As she went from clinician to clinician, her notes were recorded on different systems, some paper, some electronic and this meant vital information was not properly passed on, the inquest heard.

There was a fundamental misunderstanding early on, too, that she had been examined by a senior doctor in adult A&E, when in fact he had never seen her, the jury was told.

He was relying on a nurse’s examination when he had decided she was well enough to be transferred, and that her elevated heart rate was probably anxiety, the court was told.

But this misunderstanding led other clinicians to believe her case was not urgent and when she was sent home they believed she had tonsillitis.

The jury returned a narrative conclusion, finding that Lila died of natural causes and the cause of death was meningitis. They also decided her death was contributed to by neglect.

Coroner Christopher Morris said to Lila’s family: “I can’t even begin to imagine how difficult it must have been sitting through evidence and having to relive the events.”

He said he hoped it gave some answers to the events leading to her death and offered his condolences.

The coroner made several prevention of future death reports and recommendations to the trust.

Ms Mincherton said it was “vital that lessons are learned to improve patient safety”.

Speaking outside court, she said: “Throughout this process we have faced a number of defences to the care Lila received.

“We got the outcome today that we believed we should have but hearing the word ‘neglect’ is something a parent should never have to hear.

“We are now left with the devastating loss of our daughter for the rest of our lives.”

Tameside and Glossop Integrated Care NHS Foundation Trust, which runs the hospital, released a statement offering their condolences to Lila’s family.

“It is clear from the independent investigation that there were missed opportunities in Lila’s care. We accept the coroner’s findings and apologise unreservedly,” a statement read.

“As a trust we have made and will continue to make improvements to ensure we learn from this case.”