A six-year-old girl who was thought to have died of sepsis actually had a rare blood disorder caused by an E.coli infection, a study has found.
Coco Rose Bradford died at Bristol Royal Hospital for Children on July 31, 2017, having been transferred from the Royal Cornwall Hospital, known as Treliske Hospital, three days earlier.
Her death was the subject of an independent review published in fall 2018, which found that opportunities to treat sepsis had been missed and criticized the care given by Treliske staff.
In particular, doctors have been criticized for not administering antibiotics sooner.
The Royal Cornwall Hospitals Trust even apologized to Coco’s family for failing to identify and treat sepsis.
But on Friday, coroner Dr. Andrew Cox in Truro determined that Coco had died of multiple organ failure caused by hemolytic uremic syndrome (HUS).
The condition is caused by toxins released by E. coli infection and results in the destruction of red blood cells followed by the clotting of platelets in the small blood vessels.
It mainly 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, leading to severe brain damage.
There is no proven treatment for HUS, but antibiotics are not recommended because they can cause E.coli to release its toxins and make the disease worse.
Over the course of an eight-day investigation, a microbiological report finding “overwhelming sepsis/HUS” was found to have been taken out of context.
In his conclusions on Friday, Mr Cox noted that none of the other tests suggested Coco was diagnosed with sepsis.
He said it was “deeply regrettable” that the family had been misled over the past four years, adding, “In fact, I find Coco had overwhelming HUS, not overwhelming sepsis.”
During the inquest, the court heard that Coco’s family found Treliske’s staff to be “dismissive, rude and arrogant” and did not take her condition seriously.
In addition, there were supply deficiencies such as blood pressure measurement only 36 hours after admission and “suboptimal” fluid management.
Mr Cox noted that while staff had recognized the HUS risk from the moment Coco was admitted, this was not clearly spelled out in a ‘solid’ management plan for everyone involved in her care.
Noting that doctors had failed to provide Coco with adequate fluids throughout the day on July 27, he described this as an “apparent fundamental failure of care” that undermined previous good treatment by staff.
However, he concluded that the delay in initiating “robust fluid therapy” was “not, considering the likelihood, a cause of her death.”
There was a delay in escalating Coco’s care to Treliske’s intensive care staff, Mr Cox noted, although an adviser had discussed moving her to an intensive care unit in Bristol.
The coroner said this lack of communication made Coco “a kind of hostage to luck.”
Mr. Cox noted that Coco died of natural causes, specifically HUS, which occurred as a complication of E.coli infection.
He said it was important to say Coco didn’t have sepsis, as has been widely accepted for the past four years.
“The suggestion that Coco died of sepsis has, to my knowledge, been widely misreported in both local and national media,” he said.
“I think it is in the public interest to correct the position.”
Coco’s family said in a statement that they needed time to come to terms with the inquest’s conclusions, adding: “Four and a half years after Coco’s death, three years after the Trust fully accepted a number of shortcomings in her care, we have heard for the first time in court the suggestion that Coco did not have sepsis.”
They said further revelations about flaws in Coco’s grooming made them feel “we’ve been misled for years.”
“Whatever the court found, we will never be able to erase from our minds the experience of our time at Treliske – in many ways we have more questions than answers,” they said.