Advising with empathy and experience

Sepsis death of girl who had been sent home twice.

A young girl who dreamed of studying at Cambridge died of sepsis after being sent home by an NHS weekend walk-in centre.

An inquest in Derby heard medics missed opportunities to save twelve-year-old Franchesca Pawson when she visited the NHS centre twice in a weekend.

The centre told her to take paracetamol and ibuprofen after nurses failed to detect the infection that was spreading through her body.

The girl’s mother took her to the clinic in Derby because had been unwell for five days and complaining of fever, a high temperature and a rash.

Notes were not kept by the centre and the schoolgirl was not properly checked before being sent home with antibiotics, the inquest heard.

The child was seen by two nurses, the first examined her for “two to three minutes” before passing her on to another member of staff after diagnosing “a viral infection”. She told the girl’s mother to give her daughter painkillers.

Deputy coroner for Derbyshire, Louise Pinder, said this was a "missed opportunity to escalate Franchesca's care.”

Franchesca, who was born in Ecuador, returned the next day when her condition failed to improve, but was given antibiotics and again sent home.

The next day, 48 hours after first being seen, her parents rushed her to Royal Derby Hospital, where she died.

In a narrative verdict the deputy coroner ruled that Franchesca died from natural causes, namely toxic septic shock associated with necrotising bronchopneumonia.

She added: “The significance of her deteriorating condition during the weekend went unrecognised by healthcare professionals who assessed her.

“The bronchopneumonia remained undiagnosed and untreated until Sunday afternoon. The empyema remained undiagnosed, despite chest pain, and  was untreated until her admission to hospital on Monday.

“There was a failure to escalate her care over the weekend, despite clinical findings falling outside the normal parameters.”

The inquest was told that on both occasions Franchesca attended the walk-in centre, which used to be run by Derbyshire Health United, she was seen by nurses who admitted they had failed to document her condition properly.

Royal Derby Hospital medic, Dr Richard Bowker, said Franchesca's condition should have given staff at the walk-in centre "real concerns.”

He said there were signs of septicaemia on the Saturday and Sunday when Franchesca visited the walk-in centre.

When asked by the deputy coroner if Franchesca's respiratory rate of 22 would give him real concerns, he said: "I think there were signs on Saturday and Sunday of a high heart rate which would have made it a concern."

 

 

 

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