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Verdict of medical misadventure returned in death of baby girl from Strep A infection

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Seán McCárthaigh

A mother of a baby girl (2) who died of invasive Group A Strep infection in hospital just over 48 hours after she had originally been discharged from its emergency department with a suspected throat infection has claimed she has lost trust in Ireland’s healthcare system.

An inquest at Dublin District Coroner’s Court on Tuesday returned a verdict of medical misadventure in relation to the death of Phoenix Graham-Hadyen from Malahide, Co Dublin at Children’s Health Ireland at Temple Street in Dublin on November 3rd 2022.

Coroner Clare Keane said there was evidence that there had been missed opportunities and delays in her treatment, while there was also “not full awareness” among hospital staff of guidelines on sepsis.

Treatment

Dr Keane observed that the treatment of sepsis was time-critical as it could lead to septic shock with “every hour of delay increasing the risk of death.”

She also noted that communications with busy doctors within the hospital were “in a lot of different ways” and needed to be restructured.

The inquest heard that the little girl had been brought to the hospital’s emergency department on October 31st 2022 after she had been unwell for a number of days.

Phoenix’s mother, Lauren Graham, said her daughter had been vomiting and eating and drinking less than normal, while she had developed a cough as well as high temperature.

Ms Graham said her daughter’s temperature was over 41ºC on her first visit when she was so weak that she could not stand up.

“It was out of character as she was usually full of energy,” said Ms Graham.

Viral infection

She said a doctor examined Phoenix at around 2.30am on November 1st 2022 and diagnosed her as having a viral infection.

Ms Graham said the doctor tried to give her daughter some steroids, but she spat most of it out.

She recalled being advised to give the girl some Calpol, Neurofen and fluids when they got home.

However, Ms Graham said she was unhappy that her daughter was being discharged as she remained concerned that Phoenix was still not well and appeared very drowsy.

She returned with Phoenix to CHI at Temple Street at around 2pm on November 2nd 2022 but her condition deteriorated around 6.30pm.

Ms Graham said it looked like hospital staff had “no clue what they were doing.”

She recalled how she was later advised to say goodbye to her daughter.

However, Ms Graham said she would not have allowed doctors to have Phoenix her without seeing father “if I knew she was not going to wake up.”

The inquest heard that the girl’s family were informed in the early hours of November 3rd 2022 that she was brain dead and she passed away at 4.26am.

“I really can’t put into words the pain, loss and sadness we feel every single day,” said Ms Graham.

“My trust in the health system is completely gone” she remarked.

Ms Graham said she suffers panic attacks and fears when she hears any of her other two children with a cough.

She said Phoenix’s older brother, who has autism, has difficulty in understanding why his sister is never coming back.

She described her daughter as a little princess yet a tomboy who was “outgoing, funny, crazy and sassy.”

Impact

Her partner, Wayne Hayden, said he was devastated by the loss of his “perfect, blonde, blue-eyed girl” who should be running around playing with her older brother, Jake (8) and younger sister, Bayleigh (1).

Mr Hayden said her death had also had a huge impact on his own mental health.

The inquest heard that he had been unable to hold down regular work and had been in three different jobs over the past year.

Mr Hayden said he kept seeing the same vision in the corner of his eye of ICU staff trying to revive his daughter.

He said he and Lauren were often too consumed with grief to be able to help each other.

Mr Hayden said he also found it difficult to get over the fact that he had not got to say goodbye to Phoenix before she had been sedated shortly before her death.

He said he was still reliving that one year later.

“I have to live with that for the rest of my life,” he added.

Strep infection

The inquest heard postmortem results showed Phoenix died from invasive Group A Strep infection and pneumonia secondary to RSV – a common viral infection in young children.

A pathologist, Michael McDermott, told the inquest that it had been an unprecedented year for invasive Group A Strep infection in Ireland.

Dr McDermott said it had caused “considerable alarm and distress” for the health services with over 170 people being admitted to hospital with the infection between October 2022 and the end of this summer.

“It’s an extremely high number and many were extremely ill,” he remarked.

Dr McDermott said half of all patients with invasive Group A Strep infection over the period had required surgical intervention with 12 fatalities recorded.

He also stated that the infection was disproportionately virulent among young children.

Review

The pathologist said a review was being carried out to establish the exact reason for such a “wave of infection” but added that there was a working theory that it emerged when people were mixing together after a long period of lockdown due to the Covid-19 pandemic.

A consultant paediatrician, Claire Mattimoe, told the inquest that she had “examined and flagellated” herself repeatedly over the girl’s death.

The consultant said she was aware that Phoenix had a high pulse but that guidelines for sepsis said that left three hours to provide treatment unless there was more than one “red flag.”

However, Dr Mattimoe said she felt subsequent time delays “were what impacted” on the patient.

She told the inquest that lessons had been learnt from Phoenix’s death with several changes implemented at CHI at Temple Street including fast-tracking of X-rays for patients in the emergency department, two consultants working at night and a large increase in nursing staff.

However, Dr Mattimoe admitted that the uptake on a form used to document potential sepsis in patients “has not been great” and was only completed in 13 per cent of children with invasive Group A Strep.

A paediatric registrar, Freya Guinness, said Phoenix had been discharged after her first attendance at the hospital as she had met the criteria to be allowed home including that she was “not clinically dehydrated.”

Dr Guinness admitted to the coroner that the emergency department on the night was “extremely busy” and “short-staffed.”

She confirmed that the working diagnosis was that Phoenix was suffering from a viral upper respiratory tract infection.

Cross-examined by counsel of the deceased’s family, Ellen Gleeson BL, why the full sepsis protocol had not been activated in the girl’s case, Dr Guinness said emergency care was more about constant reassessment of vital signs.

She added that hospital staff would have to complete the protocol in around 50 patients in the emergency department every day if they adopted the full protocol in every potential case.

Dr Guinness said it was also the case that “pieces of paper” recording the risk of sepsis in patients tended “to go missing.”

Another consultant paediatrician, Louise Kyne, said a key issue in the treatment of the girl was the recognition of sepsis.

Dr Kyne acknowledged there had been a delay in considering the diagnosis of sepsis, in treating sepsis and subsequently in administering an intravenous antibiotic.

Offering her condolences to Phoenix’s parents on their “heartbreaking loss”, Dr Keane said she would ask the HSE to consider introducing an early warning scoring system for all children with a suspected infection in a hospital’s emergency department and not just on admission as is the current practice.

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