A six-year-old girl who died of sepsis was actually suffering from a rare blood condition resulting from E.coli infection, an investigation has found.
Coco Rose Bradford died on 31 July 2017 at the Bristol Royal Hospital for Children, having been transferred three days earlier from the Royal Cornwall Hospital, then known as Treliske Hospital.
His death was the subject of an independent review published in autumn 2018, which found that opportunities for sepsis treatment were missed and critical to the care provided by staff at Treliske.
In particular, doctors were criticized for failing to deliver antibiotics as quickly as possible.
The Royal Cornwall Hospitals Trust also apologized to Koko’s family for failing to recognize and treat sepsis.
But on Friday, Dr Andrew Cox, the coroner sitting at Truro, found that Koko had died of multiple organ failure due to hemolytic uremic syndrome (HUS).
This condition is caused by toxins released from an E.coli infection and sees the destruction of red blood cells after platelets form clots in small blood vessels.
It primarily affects the kidneys, but can also affect other organs, including the brain – especially in children – causing confusion and, in some cases, seizures.
HUS can cause tissue death in the brain, which can result in serious brain damage.
There is no proven treatment for HUS, but antibiotics are not recommended because they can cause E.coli to release its toxins, which can worsen the disease.
I think Coco had a tremendous husband, didn’t have massive sepsisColonel Andrew Cox
Over the course of eight days of investigation, it emerged that a microbiology report searching for “massive sepsis/husband” had been taken out of context.
In his conclusion on Friday, Mr Cox commented that none of the other tests indicated that Koko had a diagnosis of sepsis.
He said it was “deeply regrettable” that the family had been misled for the past four years, adding: “Indeed, I think Coco had severe sepsis, but heavy husband.”
During interrogation, the court heard that Coco’s family felt that Trelisk’s employees were “dismissive, rude and arrogant” and did not take her position seriously.
There were also failures in care such as not having her blood pressure taken until 36 hours after she was admitted, and “sub-optimal” fluid management.
Mr Cox found that although employees had recognized the risk of husbandry from the time Coco was admitted, it was not explicitly set out in a “robust” management plan for everyone involved in her care.
He said doctors failed to give Coco the proper fluids throughout the day on July 27, describing it as an “apparent basic failure of care” that undermined the previous good treatment given by staff.
But he concluded that the delay in starting “robust fluid therapy” was “not the cause of his death on the balance of probability”.
Mr Cox found that there had been a delay in extending Coco’s care to the intensive care staff at Treliske, despite the fact that a consultant had discussed transferring her to an intensive care unit in Bristol.
The coroner said that this lack of communication has held Coco “hostage to fate”.
Mr. Cox found that Koko died of natural causes, specifically HUS resulting from an E. coli infection as a complication.
He said it was important to point out that Koko did not have sepsis, as has been widely accepted for the past four years.
“The suggestion that Coco died of sepsis, as I understand it, has been widely misreported in both local and national media,” he said.
“In my judgment, it is in the public interest to correct the situation.”
Koko’s family said in a statement that they needed time to come to terms with the conclusion of the investigation, adding: “Four and a half years after Koko’s death, the trust has been unable to fully acknowledge a series of failures in her care.” Three years later, we heard for the first time in court the suggestion that Koko did not have sepsis.”
He said further revelations about the failures in Koko’s care made him feel “we have been misled over the years”.
“Whatever the court found, we will never be able to erase the experience of our time at Treliske from our minds – in many ways we are left with more questions than answers,” he said.
“Coco should be in secondary school now, she should brighten up our lives with her beautiful smile and live her best life. We would never get on with life without Coco in it.”
The Royal Cornwall Hospital NHS Trust has been contacted for comment.