The string of ‘rudimentary’ errors had a ‘direct and causal link’ to Evelyn Porter’s death, the hearing was told.
The coroner found that these failings were so severe they amounted to ‘neglect’, reports the Manchester Evening News.
The little girl, who had Down’s syndrome, was dashed to A&E by her parents at about 10am on July 4 2018, after a spell of persistent vomiting.
However, she died just five and a half hours later at Wythenshawe hospital.
Following a post-mortem Manchester University NHS Trust, which runs the hospital, carried out its own investigation into Evelyn’s death.
Dr Lucy Hartley, who was part of the investigating team, told the inquest that if Evelyn’s care had been better it was likely she would have survived.
Dr Hartley, a consultant paediatric anaesthetist at Royal Manchester Children’s Hospital, said: “I feel on the balance of probabilities that if Evelyn had been managed more appropriately and if a significant amount of fluid had been given to her earlier then it’s likely she would have survived.
“It is the view of the trust that but for the care issues identified Evelyn’s death could have been avoided.”
Manchester Coroner’s Court heard Evelyn was seen within an appropriate timescale but blood tests, which showed she was dehydrated, weren’t ‘acted upon appropriately’.
A&E medics tried unsuccessfully five times to give Evelyn intravenous fluids, but it wasn’t until four hours later fluids were actually administrated, the investigation found.
Nurses tried and failed to take her blood pressure on a number of occasions. The failure was put down to a machine malfunction but a different machine wasn’t sought.
An early warning scoring system, which determines the severity of a child’s condition and the scale of the response, wasn’t calculated properly meaning senior consultants weren’t involved soon enough and observations weren’t carried out with the necessary frequency.
Dr Hartley said that had Evelyn been given fluids, an investigation could have been carried out to identify the obstruction in her intestines and then surgery could have been performed.
Consultant paediatrician Dr Naveen Rao, who was also part of the investigating team, said an ‘action plan’ of 10 points had been drawn up following the investigation, all of which had since been put in place.
He added: “There is ongoing training so the systems are there to help staff escalate care as required.”
Sefton Kwasnik, representing the family, said the failings amounted to ‘gross neglect’.
He added: “The collective and cumulative failings were within a very short period of time, from around 10am to 3.30pm.
“We are talking about 330 minutes of care in the hospital. It’s the collective and cumulative effect of individual and systematic failings.”
Coroner Zack Golombeck said there had been a ‘gross failure of medical attention’ and that there was a ‘direct and causal link between the gross failures and Evelyn’s death’.
He added: “The trust’s investigation found that there were a number of care problems in respect of Evelyn’s death and that these problems materially contributed to her death.
“Time critical deterioration wasn’t recognised early enough and as a result Evelyn’s care and treatment wasn’t acted upon early enough.
“Whilst I must credit the trust for the candour they have displayed that takes nothing away from the tragedy of this case.
“It’s clear there were a number of failings in the care afforded to Evelyn. I find that taken together as a collective they represent a gross failing in care.”
Mr Golombeck gave a narrative conclusion.
He said: “Evelyn died as a result of her deterioration not being recognised which resulted in her condition not being treated in a timely manner.
“The deceased’s death was contributed to by neglect.”
In a statement a spokesperson for the Manchester University NHS Foundation Trust said: “We wish to apologise unreservedly to the family of Evelyn Porter and our deepest sympathies continue to be with them at this incredibly sad time.
“Following the conclusion of today’s inquest, the trust fully accepts the findings made by the coroner and we have already undertaken a number of actions to ensure lessons are learned to improve patient safety and care.”