Hospital blunders led to girl’s death

Shortages of senior medics, delays, and out-of-date medicines meant the trust was unable to stop epileptic Arina Durbazeva fitting before she suffered a heart attack, Chelmsford Coroners’ Court heard.

Arina, from Maunder Close, Grays, was born at the hospital and had been a regular patient after being diagnosed with epilepsy, aged one.

She was admitted to the paediatric unit on October 12, last year, for checks after suffering an epileptic seizure at school, which stopped after being treated with an anti-seizure drug.

However, she had a second seizure at the hospital soon after arriving at 4.20pm, but a series of subsequent errors meant it could not be contained.

She suffered the heart attack at 6.05pm and stopped breathing for 14 minutes before being transferred to St Mary’s Hospital, London, where she died two days later.

Giving a narrative verdict Coroner Caroline Beasley- Murray said: “There were serious failings in the care provided during her treatment at Basildon Hospital.”

The failings were:

•  No set treatment plans for regular patients ! An inexperienced medic struggled to mix a dose of the same drug used to stop the previous seizure and the delay meant it did failed to work.
• Junior doctors chose not to administer three other types of drugs which should be tried if the first treatment failed, as the only stocks on the ward were out of date. It was later established they should have been tried anyway.
• Pharmaceutical staff should have replenished and destroyed out-of-date drugs, but failed to do so ! Despite warning signs under a child patient risk system, there were repeated delays in alerting an on-call consultant to her deteriorating condition ! A lack of senior nursing staff, no senior doctors were ever at the ward after 5pm and the oncall locum consultant Dr Mohamed Ramadan chose to stay at home when contacted.
• Two anaestistists on site could not get to her bedside until after the heart attack.

A post mortem found she died from multiple organ failure contributed by epilepsy, an associated brain problem and obesity.

The court heard the death also led to two independent reviews and an action plan to prevent a repeat being implemented.

It included regular drug date checks, consultants on site until 9pm, tailor-made care plans for those with complex illnesses, and staff made to contact senior staff more quickly.

Ms Beasley-Murray added: “I am pleased to see there have been some improvements in places, but they must be ongoing and must be implemented.

“There is no point having an action plan unless it is implemented fully so little girls like this much-loved girl are not at risk.”

ARINA’S father still wants answers from Basildon Hospital over his daughter’s death.

Arkadiys Durbazeva, 40, cross examined Dr Rotimi Jaiyesimi who investigated the failings.

He said: “There is a void in our understanding of how a situation as dire as this was allowed to exist in the hospital.”

He did not accept some of the doctor’s claims and timescales given in evidence.

The hospital said the seizure lasted 45 minutes, but Mr Durbazev said records showed it was an hour and 45 minutes.

Despite being in charge of the investigation, Dr Jaiyesimi said he could not comment on why other measures recommended in the treatment plan for epileptics were not carried out.

There was also confusion over the timing of when the anaesthetists were first contacted, two other calls made by junior doctors, and who was in charge during her treatment, which the medic was unable to address.

Mr Durbazeva added: “There are definite discrepancies between our understanding and the definitions of certain events given this afternoon and the timescales. Unless we get satisfactory answers, we reserve the right to seek further responses.”

The court heard evidence of failings in her care that typified the myriad of problems identified by the national review into failing trusts across the country, which singled out several hospitals, including Basildon, with the highest preventable death rates, having severe staff shortages and lack of senior doctors available at the busiest times.

DOCTOR Rotimi Jaiyesimi, Basildon Hospital’s director of patient safety, carried out an internal investigation into the death.

He accepted there was a delay in mixing the initial drugs.

He said: “Perhaps the person mixing it did not know what to do. If it had been a senior person perhaps it would have been given earlier.

“In years gone by nursing staff had responsibility for out-ofdate drugs, but there were documents saying it was the responsibility of pharmacy, but they did not do it.

“There was a delay in escalating treatment when the first treatment was not effective.

“I would expect junior doctors to have contacted consultants.”

On call consultant Dr Ramadan no longer works for the trust and is based in Libya, so did not give evidence.

Dr Jaiyesimi added: “The consultant should have probed further about the deterioration. It is difficult for me to comment on his decision to stay at home.”

Asked about repeated delays in getting consultants involved, he added: “When you are in a bubble, you lose track of time.

“We have spoken about it across the trust and if a junior doctor calls. you must ask relevant questions.“ BASILDON Hospital’s chief executive Clare Panniker gave a personal apology to the family after the inquest.

She said: “I want to say how sorry I am that we failed to provide the best care to Arina.

“I also want to assure her family that she will not be forgotten and will remain at the forefront of our minds as we seek to improve the care we provide to all our patients.

“We have worked tirelessly to learn lessons from her death and, as a result, the care we provide to children has been transformed.”

She said the hospital now employed higher numbers of specialist paediatric nurses and three additional consultants. She added: “We have changed the way some children access paediatric services out of hours to ensure they are safe at all times.

“A review of the way we manage medicines has also been undertaken to ensure they are available and in stock at all times.”