‘Basic failures in care’ did not cause Coco Bradford’s death, inquest finds

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The death of a six-year-old girl was not caused by failings and delays to her care by Royal Cornwall Hospital, a coroner has found.

Coco Bradford, 6, died on July 31, 2017, at Bristol Children’s Hospital of multiple organ failure caused by an aggressive form of a rare kidney infection, itself caused by e-coli.

An inquest into Coco’s death opened in December, concluding today (Friday, January 14), overseen by coroner Andrew Cox.

Read: Doctor apologises to family after young Coco’s death

Parents Rachel and Luke, from St Ives, rushed Coco to Royal Cornwall Hospital (RCH) at Treliske on July 24, 2017, after their daughter had been vomiting and had diarrhoea.

After she was given fluids and appeared to take them on, Coco was discharged from hospital on the same day and the parents told to return if her condition worsened.

She continued to pass liquid and bloody stools and could not hold down any fluids, so was rushed back in on July 25.

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Coco remained at RCH for three days as her condition worsened before being transferred to Bristol Children’s Hospital, where she died.

She suffered Hemolytic Uremic Syndrome (HUS), a rare kidney condition, as a result of e coli 157, a bacterial infection.

It was later found that there were several missed opportunities from doctors and consultants to catch the condition sooner.

Reading from a nearly 40-page conclusion, Mr Cox went over the evidence heard from every day of the six-day inquest.

He highlighted the “main issues” in his summary, having heard evidence from doctors who tended to Coco, two experts on paediatric care and from mum Rachel.

The first was Coco being sent home on July 24 by Dr Diaz Reales, who Mr Cox said gave “insufficient thought” about what could happen when Coco was sent home, and that he had disregarded reports from ambulance staff about blood in mucus and stools.

Luke and Rachel Bradford with their autistic daughter Coco
Luke and Rachel Bradford with their autistic daughter Coco

At an earlier hearing, Dr Nelly Ninis criticised the decision to send Coco home at this stage.

In her experience, Dr Ninis told the coroner’s court child patients might be sent home even if they look very unwell, as Coco did. However, she clarified that in a “remote” hospital like Treliske, an admission to a ward should have been considered given how far away patients are.

Rachel told the coroners’ court earlier in the inquest that Coco, who was autistic, had been labelled “uncooperative” by hospital staff and that this was a reason care was insufficient.

On Coco’s return to the hospital, on July 25, 2017, she was admitted again with a worsened condition including confusion.

HUS has no cure, but Dr Ninis explained to the inquest that giving more bolus – small amount – of fluid earlier increases the chances of survival and that the symptom of confusion should have been given more thought.

Between July 25 and July 28, when Coco was transferred to Bristol, she was given multiple bolus of IV fluids via IV drip.

However, based on the accounts of Drs Goyal, Guilder, Collinson, Hopkins, and Williams who tended to her in this time Mr Cox said it appeared a lack of communication in between shifts meant not enough was administered for how serious Coco’s condition was.

As well as this, one doctor admitted he had “missed things” and failed to do important tests on Coco.

The first hearing of the inquest, on Monday, December 8, 2021, heard from consultant paediatrician Dr Andrew Collinson.

During the hearing, Dr Collinson said: “When I saw Coco I made mistakes. I missed things and I got things wrong. I don’t remember looking at Coco’s observation charts, which recorded her temperature, pulse, respiratory rate and vitals signs.”

He also said he wanted to apologise to the family and he “didn’t do enough”.

Similar criticisms were levelled at RCH for delaying a transfer from the regular paediatric ward Coco was on to intensive care, and then on to Bristol – partly driven by a breakdown in communication between the two hospitals.

As well as this, Mr Cox pointed to RCH nurses’ failure to weigh Coco – a crucial step for monitoring fluid retention and giving out the right medicine doses – and for taking so long to send off stool samples for analysis.

Wrapping up, Mr Cox said the aggressiveness of Coco’s HUS meant she became “a hostage to fortune” who likely could not have been saved even if her treatment was perfect.

However, he issued stark words to RCH which he noted had made many changes since July 2017.

He said: “Coco became a hostage to fortune. When her condition was apparent, I consider she should then have been transferred to intensive care.

“Going forward, RCH may wish to consider where a paediatric patient needs a transfer – whether for renal support or advance support – it will be appropriate for that patient to be managed from intensive care where they can be checked on more frequently.

“This will depend on other factors such as bed availability.

“Once it became clear she had developed HUS and needed organ support she became too demanding to be on a regular paediatric ward. At that point she should have been transferred to intensive care at Treliske.”

Luke and Rachel Bradford with their daughter Coco in St Ives
Luke and Rachel Bradford with their daughter Coco in St Ives

Despite the “basic failings”, however, the inquest also heard from Dr Tse, who said they did not contribute to Coco’s death in a more than negligible way.

Dr Ninis did not dispute this conclusion from Dr Tse but said staff at RCH should have given her more fluids, given her antibiotics earlier and communicated better between departments.

Mr Cox, in his summary of the case, said he agreed with Dr Tse and that the failures in basic care for Coco did not cause her death.

He said: “I accept the evidence of Dr Tse that, given the overwhelming nature of the HUS coco developed, the delay in initiating Coco’s fluid therapy robustly and then maintaining it throughout July 27 were not causative of her death on a balance of probability.”

The coroner came to the same judgement regarding the nursing failures, sending her home on July 24, the delay in sending her to Bristol, and the delay in giving her antibiotics to treat suspected sepsis.

He further confirmed Coco at no point had sepsis, as earlier reported by the media and by a former RCHT boss who mistakenly said the trust had “missed” a diagnosis of sepsis.

Mr Cox apologised for the publication of this “misleading” fact and finished by recording a conclusion of natural causes for Coco’s death, in particular HUS from an e-coli 0157 bacterial infection.

He said: “The position I can summarise is this – we heard at inquest from Dr Grant of the very considerable changes made in terms of funding and investment within RCHT after Coco’s death, the report into it and review.

“We’ve heard a number of consultant paediatricians being taken on, with a net gain of three during the day and six on night shifts.

“The key concern about workloads and sufficiency of clinicians have been addressed some time ago, such as splitting the rotas.”

Mr Cox gave RCH 28 days to show evidence of new guidance to doctors in the treatment of cases like that of Coco and said he planned to write to NICE – a body which advises healthcare professionals in the UK – to ask if it could issue new guidelines in the identifying and treatment of HUS.

“I want to make sure lip service isn’t just paid to this,” Mr Cox added.

Finally, speaking to Coco’s parents Mr Cox said: “This has been an extremely long drawn out and difficult process and I’m extremely grateful to you for the considerable assistance you’ve provided.

“You’ve always treated me with courtesy and respect and I am most grateful for that.

“I hope the course of this inquest has addressed all of your concerns, I’m sorry it’s taken so long to get to this point. And I’m desperately sorry we met in these circumstances in the first place.”

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