Young girl's death in Broomfield Hospital 'could have been prevented', coroner says
The death of a three-year-old girl could have been prevented if NHS staff at an Essex A&E department had followed sepsis guidelines, a coroner has concluded. Zadie Ajetunmobi died from natural causes in Broomfield Hospital in 2022 - but had failures not happened in her care, she may have survived.
Three-year-old Zadie was admitted to the hospital's A&E department in November 2022 with a high temperature but died hours later following a cardiac arrest. Her parents have said they will "never recover" from the loss of their daughter after a narrative conclusion was delivered by Senior Coroner Lincoln Brookes on September 17.
The Mid and South Essex Hospitals Trust which runs Broomfield Hospital has acknowledged it "missed opportunities" to help Zadie and has addressed their emergency care model for children since the "tragic" incident.
Read more: Girl, 3, dies hours after going to Broomfield A&E because 'doctors didn't recognise her symptoms'
Read more: Road taped off by police as man hospitalised with serious injury after attack
In his conclusions, Coroner Brookes said that while Zadie died of natural causes, she should have been treated in line with sepsis guidelines within an hour of arriving at Broomfield Hospital and had this been done, her death would likely have been prevented.
Following the conclusion, Zadie's parents Theo and Rhiannon Ajetunmobi said: "My wife and I are grateful to HM Coroner Brookes for his thorough and searching analysis of the issues surrounding Zadie's death. We are, of course, devastated to have heard very clearly in the last two days that Zadie's death was avoidable.
"This is a tragedy from which we will never recover and which we hope no other parents ever have to endure. We urge Broomfield Hospital and those who were on duty that night to learn all necessary lessons from our terrible experience. The Inquest has confirmed that had the hospital’s sepsis guidance been applied, Zadie's symptoms would have triggered the sepsis pathway and she should have been given intravenous antibiotics within an hour.
"It is beyond painful to know that if Zadie had been given the intravenous antibiotics she would have survived. No apology, coroner or NHS report can take away our heartache or bring our beautiful little girl back. But we hope the examination of the events surrounding Zadie's death helps to prevent future tragedies.
"We would like to thank all those who have supported our family throughout this process. We urge other parents to learn more about sepsis, to be aware of the signs and to raise concerns with medical professionals if you ever have any doubts about your child's symptoms."
Andrea Wadden, clinical negligence solicitor with the Kingsley Napley LLP who represented Zadie's family, said: "We are pleased to have been able to support Mr and Mrs Ajetunmobi through this process and are full of admiration for the dignified and calm way they have approached the Inquest and having to relive the harrowing events of 11 November 2022.
"Having examined the circumstances in great detail, HM Coroner Brookes has now provided his conclusion confirming that while Zadie died of natural causes, she should have been treated in line with sepsis guidelines within an hour of arriving at Broomfield Hospital and had this been done, her death would likely have been prevented.
"The trust says it has already taken a number of steps to prevent similar tragedies from occurring and following HM Coroner Brookes’ findings, we hope they will ensure the sepsis toolkit and guidance is followed at all times and enhanced training is consistently implemented for all staff in A&E.
"Sadly there have been a number of fatal cases of sepsis relating to children in the news recently, but we hope the continued attention on cases such as Zadie’s will result in a change of practice in the future and a focus on lifesaving sepsis guidance.”
Diane Sarkar, Chief Nursing and Quality Officer for the trust, said: "Our sincere condolences go to Zadie’s family at this very difficult time. We know we missed opportunities to act more quickly to prevent Zadie’s death. We investigated her case thoroughly and took immediate action to ensure that better processes were in place following this tragic incident. We continue to keep our emergency care model for children under close review to improve safety and confidence in our care."