An NHS Trust has admitted its catastrophic failures led to the tragic death of a vibrant three-year-old girl after medics failed to spot that she had sepsis.
Zadie Ajetunmobi was taken to Broomfield Hospital in Chelmsford, Essex with tell-tale signs of the deadly infection including a high temperature and a rapid heart rate.
However, doctors, who wrongly diagnosed her with tonsillitis, failed to administer intravenous antibiotics for more than seven hours leading to the child suffering a fatal cardiac arrest.
The Mid and South Essex NHS Foundation Trust yesterday admitted that had medics followed sepsis guidelines little Zadie would still be alive today.
Lawyers representing the Trust told Zadie’s devastated father Theo at her inquest in Chelmsford Coroner’s Court that it is ‘extremely sorry’ for the catalogue of deadly errors in November 2022.Â
The family of three-year-old Zadie (pictured) who died in November 2022 are seeking answers at an inquest
In a letter of admission read to the hearing the Trust revealed that an internal investigation had found that medics had ‘failed to recognise how sick Zadie was’.
It admitted there was a delay in treatment and that the sepsis pathway in place at the time was not implemented.
‘Had the sepsis pathway been triggered at triage, intravenous antibiotics would have been administered to Zadie within an hour.
‘Had intravenous antibiotics been administered in an hour, along with other supportive care…Zadie would not have suffered a cardiac arrest when she did and would have survived,’ the letter said.
Among the other key failings, the Trust said staff failed to assess the child early warning tool (CWT) score correctly and that there was a lack of review by an ‘appropriate senior clinician’ at A&E.
It acknowledged that the results were ‘absolutely tragic’, adding: ‘Those at the Trust deeply regret the failures that took place and are extremely sorry.’
The inquest also heard damning evidence that Zadie was not seen by a doctor for more than three hours after her arrival at accident and emergency at 9.40pm on November 10, 2022.
Medical records showed that staff had continually failed to raise the alarm despite Zadie’s heart rate reaching more than 180bpm and her temperature peaking at 40c.
Expert witness Dr James Gray, a microbiologist based at Birmingham Children’s Hospital, said that Zadie most likely had Strep A and her vitals should have triggered the sepsis pathway.
‘There was a clinical picture that Zadie’s condition had deteriorated…but for reasons, that are not for me to comment on, she neither received antibiotics or the level of support that I would have expected by the blood results and Zadie’s condition in terms of physiological measurements taken at triage.
‘I would have expected that Zadie would have entered the sepsis pathway and she would have received the full sepsis bundle,’ which he said includes antibiotics, intravenous fluids and close monitoring.
The expert who examined her records added that despite the signs antibiotics were not administered until just after 5am in the morning – she died just two hours later.
Dr David Sanwu, a junior doctor who assessed Zadie in A&E at 1am, admitted that he had not suspected sepsis because she did not appear to be extremely unwell.
However, he said that he had not been familiar with the national sepsis guidance adding: ‘This particular tool at that stage I had never used.’
He concluded his evidence by apologising to the family saying: ‘This is the worst case I’ve been involved with in my medical career and is one which will stay with me.’
Zadie was rushed to Broomfield Hospital (pictured) with a high temperature but died ten hours later after a cardiac arrest
Earlier the inquest heard heartbreaking testimony from Zadie’s mother Rhiannon who had taken her daughter to hospital while her husband stayed at home with their son.
In a statement she described how her daughter, who had a sore throat and high temperature, had suddenly deteriorated after being moved to the paediatric ward where she was given antibiotics by injection.
‘I noticed her breathing started to sound raspy and I informed the nurse… and her heart was beating very quickly,’ she added.
She said she was given a nebuliser which did not appear to help and a nurse handed her a syringe with some paracetamol.
‘I tried to give it to her but she suddenly went floppy… and I screamed,’ she said before a nurse set off the alarm and the room was overrun with medics.
‘My mind went blurry at this point, I was unable to focus on what was going around me… the next thing I remember is being informed that Zadie had passed,’ the devastated mother said.
Her husband Mr Ajetunmobi, 42, described speaking to the usually bubbly toddler just hours before her death on video call.
‘We gave each other a thumbs up. I asked her to smile and she flashed a micro smile which faded quickly,’ he said.
Speaking of his daughter’s untimely death, the teacher added: ‘Rhiannon and I have been devastated by the loss of Zadie.
‘She made our family whole, she was cherished and loved and brought so much joy…Words cannot express the depth of loss we feel as a family.’
The father said in his statement that the impact of her loss had been compounded by the fact that she died ‘needlessly’, adding that if the right procedures had been followed she would still be alive.
