Girl died after missed opportunities, inquest finds

There were "missed opportunities" to treat a four-year-old girl who visited A&E and a GP during the 48 hours before her death, an inquest jury found.

The child, Makenna-Rose Thackray, had been taken to Pinderfields Hospital, Wakefield, by ambulance two days earlier but went home after her family endured a fruitless six-hour wait for treatment. They visited a GP the following day and were sent home without antibiotics.

The inquest heard that when the child was first taken to the hospital on December 18 the two nurses on shift that night were caring for almost 80 children, instead of the 30 to 40 which could have been safely treated.

One of the nurses, Helen Parker, described the shift as "one of the worst" and, when asked if they were under-staffed, replied: "Absolutely, yes."

Makenna-Rose's mother, Danielle Ledger, took her daughter home, saying she had not been encouraged to stay although the nurse said that this was not the case and that she had encouraged Ms Ledger to remain at the hospital.

GP Dr Nand Kishar Nemana, who saw Makenna-Rose the following day, said he was not made aware that she had vomited blood or been taken to hospital by ambulance the previous night.

He diagnosed the family, from Rothwell, with flu. Makenna-Rose was diagnosed with scarlet fever, caused by the bacterial infection Strep A, on 9 December 2022.

There was a Strep A outbreak across the UK in late 2022, with pharmacists across the country reporting a widespread shortage of penicillin.

Makenna-Rose died on December 20, 2022, after she stopped breathing and went into cardiac arrest.  The medical cause of death was read in the court as natural causes, namely invasive Strep A and 1B influenza A (flu).

Before being sent out to deliberate, coroner Oliver Longstaff set out a list of facts to help the inquest jury reach a decision. 

These were that Makenna-Rose was given a PAWS (paediatric advanced warning score) of seven at 20:15 GMT on 18 December 2022 and should have been seen by a middle-grade medical professional within 20 minutes of arriving at hospital

If no observation was given within 30 minutes, Makenna-Rose should have been seen by a consultant. Observations should have continued every hour, but Makenna-Rose was not seen.

The coroner also said that the youngster should have had a blood test but was not given one. A reason why this was the case should have been recorded, but this also did not happen. Also, Makenna-Rose should have had a sepsis screening tool assessment, but she did not. 

The jury found there were "missed opportunities" in not having Makenna-Rose observed during her six hours wait in Pinderfields and that "the hospital was significantly busier than normal" which led to Makenna-Rose not being seen. 

The jury also found Dr Nemana's "management would have been different" if he had known about Makenna-Rose's hospital trip and her vomiting blood. 

In a statement, Makenna-Rose's parents, Danielle Ledger and Paul Thackray, said: "We came to this inquest hoping that those responsible for our daughter's medical care would accept some accountability for their failures and so they could learn from their failures to try prevent something like this happening again.

"It is heartbreaking to know even at this stage that, if the doctor had referred Makenna-Rose back to hospital, it is likely that she would have survived. Those who met Makenna-Rose never forgot her. She was a larger-than-life character, and a real daddy's girl. 

"She loved dancing and adored her animals, her pet rabbit and puppy, Floss, who she would take to school in her doll's pram. We all miss her so much."

A Mid Yorkshire Teaching NHS Trust spokesperson said: “We take every opportunity to learn from missed opportunities so we can continue to improve.”

Chief nursing officer at the NHS trust, Talib Yaseen, added that it was “extremely sorry for the sad loss Makenna-Rose’s parents, family and friends have suffered. Everyone at the trust is committed to providing the best possible care to our patients and we want everyone to receive the right diagnosis and the treatment they need to get better.