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Hospital’s lack of attention and knowledge directly contributed to 2-year-old’s death, inquest finds
An inquest into the death of 2-year-old Cristiana Banciu has found that a lack of attention and knowledge by hospital staff contributed to her death, after she suffered a rare response to influenza.
A coroner ruled that Cristiana - who died just before her third birthday on 8th January 2020 - would probably have had a better chance of survival if she had been transferred to intensive care sooner.
Cristiana was transferred from the Princess Royal University Hospital (PRUH) in Orpington to King’s College Hospital in Denmark Hill, south London on 6th January.
The inquest into her death, which took place at South London Coroner’s Court, heard that the toddler had been flagged as a patient of concern “multiple times” at the PRUH.
An investigation by King’s College Hospital NHS Foundation Trust found there was a “failure to adequately monitor Cristiana on the ward, a failure to detect her declining neurological condition, and to act and escalate on her low Glasgow Coma Score”.
The inquest heard how Cristiana’s parents travelled with their daughter in the ambulance to King’s College Hospital. Mr Banciu said that was the first time he had been told of the “real situation” she was in, while Mrs Banciu said that on arrival at King’s College Hospital the staff “did all they could” but that they were told their daughter had a less than 0.1% chance of survival.
Assistant coroner Jacqueline Devonish said that the failure to record Cristiana’s Glasgow Coma Score was “very serious indeed”. She said:
“It seemed to me that there was a lack of attention and a lack of knowledge which had directly contributed to this little girl’s death.”
Ms Devonish added that she is of the view that healthcare professionals “failed to provide basic medical attention”, that these were “very basic neurological observations that needed to be undertaken” and those results accurately reviewed by a senior clinician.
“In my view that’s a gross failure,” she said.
However, Ms Devonish also said the law does not support a finding of neglect due to a lack of evidence that Cristiana would have survived had she been treated sooner.
In her narrative conclusion, Ms Devonish said: “Baby Cristiana died from a rare response to influenza in circumstances where the decline in her responsiveness, Glasgow Coma Score of 8, and progressively sluggish pupils had not been recognised.
“There was a consequential delay in transfer to the paediatric intensive care unit. It is not possible to say on the balance of probabilities whether she would have survived if transferred sooner. But she would, probably, have had a better chance.”
Addressing the family, Ms Devonish said: “I’ve seen the picture of baby Cristiana on your T-shirt. She’s absolutely beautiful. And it’s an extremely sad case. I know that the family recognised early on that there was something seriously wrong, and it’s a pity that those treating her didn’t also recognise that.”
“Catalogue of errors”
She said there had been “a catalogue of errors” and added: “The tragic loss of this cheerful, resilient, beautiful, bright little angel is absolutely devastating for us all.”
Speaking after the inquest, Cristiana’s parents Alexandru and Georgina said: “Losing our daughter in such a horrific way has left us feeling like we have no reason to wake up in the morning.
“She was the apple of our eye and her avoidable death has left us beyond devastated. Wherever Cristiana went, she lit up the room with her smile and she made people happy. We never thought that by taking her to the hospital where she was born that she would never be coming home with us again.
“The doctors and nurses who failed her need to face some sort of justice as without their mistakes our daughter may well still be here today. We need to know that this will never happen again as no family should ever have to go through the nightmare we have been through.”