Fears as 'no medical record exists of examination' that led to fatal discharge of little girl

Yahoo

19-06-2025

A coroner has written to Wes Streeting over the tragedy of little Lila Marsland, who was found dead from meningitis, hours after being sent home from hospital being told she had tonsillitis.
The coroner told Mr Streeting that he is 'concerned' about how 'vital clinical information' could risk 'being lost' in a complicated 'mixture of various analogue and digital systems' in use at Tameside General Hospital.
Alarm around missing medical information include that 'no medical record appears to exist of the examination of Lila which was undertaken by the locum registrar in paediatrics which resulted was discharged from hospital'.
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The coroner also aired fears for the rest of the country's hospitals which 'continue to operate with information being stored and shared in a fragmented and disjointed way'.
Lila Marsland was found unresponsive in bed by her mum, dying from meningitis. But around eight hours earlier, the five-year-old was discharged from a long stint in Tameside Hospital as her mum was told she had tonsillitis.
Following an inquest at the start of June, which examined Lila's care and treatment at Tameside General Hospital, a jury concluded her death was preventable and 'contributed to by neglect'.
Coroner Chris Morris told the Secretary of State for Health and Social Care: 'The court heard evidence that, over the course of almost 10 hours in hospital, Lila's history and details of examinations and assessments undertaken were recorded on a mixture of various analogue and digital systems in operation in different parts of the Trust, leading to a risk of vital clinical information being lost in the system.
'I am concerned that this, and other hospitals elsewhere in the country, continue to operate with information being stored and shared between professionals in a fragmented and disjointed way.'
On December 27, 2023, Lila started getting sick. By the evening, Lila's mum - a district nurse who worked for Tameside and Glossop Integrated Care NHS Foundation Trust - knew it was serious enough to take her daughter to the trust's A&E at Tameside Hospital.
Lila was suffering headaches, a sore throat, a high heart rate, neck pain and limited neck movement, vomiting, lethargy and was unable to pass urine.
Lila was sent from adult A&E to paediatric A&E. Mum Rachel Micherton asked hospital staff if it was meningitis.
A number of nurses were concerned meningitis was a possible cause for Lila's illness but, following tests and a review by an experienced paediatric registrar doctor, decided she was more likely suffering from tonsillitis.
The five-year-old was discharged from Tameside Hospital with antibiotics and a throat spray at around 2am on December 28. Around eight hours later, she was found unresponsive in bed by her mum.
She called 999 and attempted CPR. Paramedics arrived, but Lila was pronounced dead at 9.19am.
Following the inquest last month at Stockport Coroners Court, the Greater Manchester South Area Coroner produced two 'prevention of future deaths' reports. The reports are sent to relevant authorities to attempt to stop further deaths from causes uncovered during an inquest.
Along with his letter to Mr Streeting, the coroner also wrote to the bosses of Tameside and Glossop Integrated Care NHS Foundation Trust raising fears about its lacking implementation of the National Institute for Health and Care Excellence (NICE) guidance around meningitis, and notes missing from Lila's case.
The absent notes include a record of the final review of Lila by a senior paediatric registrar before she was fatefully discharged.
The coroner's prevention report aimed at trust bosses reads: 'I am concerned that no medical record appears to exist of the examination of Lila which was undertaken by the locum registrar in paediatrics which resulted was discharged from hospital.
'The absence of this key piece of evidence serves to limit the ability of the trust to derive all possible learning from Lila's death.'
The coroner also shared fears that crucial childhood sepsis screening tools are 'not yet fully embedded in the minds of those who assess and treat children and young people at the trust'.
Mr Morris, too, aired concerns that an emergency medicine consultant who approved Lila's transfer from adult to paediatric A&E 'provided a statement to this court that they had seen' Lila 'and 'visually assessed [her] at least'.
When called to give evidence in court during the inquest, the consultant admitted this had not happened.
Earlier in the inquest, the hearing was told that in a supplementary written statement to the inquest, Dr Muhammad Farooq said: "In this case, on the request of the staff nurse, I performed a preliminary visual assessment and reviewed the patient's vital signs."
However, speaking in the witness box, he said he now accepted that was 'wrong' and he had not 'eyeballed the patient'.
"Do you accept, in this case, those words are misleading?," Mr Morris said. "It implies you had been to see Lila, or seen her from a distance."
"I accept a mistake," Dr Farooq said. "I very openly and honestly accept the mistake."
"Should you have gone to see Lila?" Mr Morris asked.
"If I would have gone to see Lila, in my final assessment I would have transferred the patient in the same manner, to the paediatric emergency department, to get her seen quickly," he said.
Asked how he knew that, Dr Farooq said: "The department was very busy and there was no space downstairs to see the patient. That was the quickest way to see the patient."
Ms Mincherton has not returned to work since Lila's death and was 'uncertain' about doing so, as she would 'need to promote the trust' that dealt with her child.
More than a year on, an inquest determined Lila died from pneumococcal meningitis streptococcal pneumonia.
The Hyde girl's death from meningitis was 'contributed to by neglect', the jury concluded after an eight-day inquest.
'Had Lila been admitted to hospital and given broad spectrum antibiotics within the first hour of being triaged, this would have prevented Lila's death,' the jury concluded.
The trust has apologised and accepted there were failings.
Ms Mincherton, outside court, said: "I would like to thank the jury for coming to this conclusion, based on the evidence provided - a conclusion I have known for 17 months.
"Hearing the word 'neglect' is something a parent should never have to hear and we are now left with the devastating loss of our daughter for the rest of our lives."
Rachael and scaffolder Darren, 42, said their lives - and that of Lila's 15 year-old sister Ava - had been 'devastated'. They have been left feeling 'empty'.
A spokesperson for Tameside and Glossop Integrated Care NHS Foundation Trust said: "We want to express our sincere condolences to Lila's family for their heartbreaking loss.
"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 for this.
As a Trust, we have made and will continue to make improvements to ensure we learn from this case."