An absolute tragedy and a family badly let down.
This is the conclusion of an inquest into the tragic death of seven-year-old Evelyn Smith who died within two hours of leaving her doctor’s surgery.
The former Coten End Primary School pupil, pictured above, had been seen by doctors and nurses three times in the 36 hours before her death on September 13 last year, as a result of a complication of croup. And that death was, more likely than not, preventable, according to the assistant coroner for Warwickshire, Dr Richard Brittain.
Speaking at the inquest on Friday, Evelyn’s mother, Helen Smith, told the court what a ‘livewire’ her lovely daughter was and how she had never had anything significantly wrong with her until the summer of 2013 when she had been diagnosed with tonsolitis on two occasions.
Both times Evelyn had responded well to antibiotics.
Even on September 11, when she woke up with a mild headache, she went to school. Mrs Smith told the inquest that when she picked Evelyn up at the end of the day she had gone on to her ballet class, even though her voice was husky and hoarse.
But at 2am on Thursday, Evelyn had burst into her parents bedroom saying: “I can’t breathe.”
Helen and her husband Trevor gave her a drink and some Calpol and drove her straight to Accident and Emergency at Warwick Hospital.
The little girl was examined by Dr Emma Sexton and vomited at the hospital, shortly before being discharged at 4.39am.
Mrs Smith said: “Evelyn’s temperature rocketed from then on. The lowest I recorded was 39.7c. On Friday morning I called the GP (at the Priory Medical Centre) because I’d been giving her the appropriate treatment for a high temperature and it wasn’t working.”
Sister Trudy Hudson, advanced nurse practitioner and respiratory nurse at the Priory Medical Centre knew Evelyn had been to hospital and when she examined her there was no wheezing and she was more concerned about her inflamed tonsils. She prescribed penicillin.
When Mr Smith was at work his wife sent him a text saying Evelyn had massively improved.
But by the time he got home on Friday afternoon, their daughter’s temperature had gone up again. They rang their GP at the Medical Centre again and were told to bring her in straight away.
Evelyn was examined by Dr Susan Martin who said the little girl had oxygen saturations and moderate croup.
Dr Martin gave Evelyn a prescription and explained that croup usually lasted for two or three nights. She made an appointment for her to be brought back on the Monday.
Two hours later Evelyn collapsed and died at home, her mother desperately giving her artificial respiration as she waited for an ambulance to arrive.
At the inquest, assistant coroner Dr Brittain concluded: “Evelyn Mary Smith died from the consequences of both a viral and bacterial infection of her upper respiratory tract.
“Her family sought medical attention three times in the days leading up to her death. There were missed opportunities to diagnose and treat Evelyn appropirately on each of these occasions. However, I am satisfied that none of these consultations were neglectful.
“Based on the evidence heard, it is more likely than not that her death was preventable; although it has not been possible to conclude the causative impact of each missed opportunity.”
As they battled with their grief, both Mr and Mrs Smith tried to get some answers from the medical profession. Mrs Smith also became the moving force behind heart resucitation training being given by the British Heart Foundation at Warwick, Leamington and Barford primary schools.
A programme she hopes will roll out across the county as most teachers would not know what to do if a pupil collapsed in the classroom.
Among those giving evidence at the inquest was Warwick Hospital doctor Emma Sexton, who first examined Evelyn on the day before she died. She said the child did not appear to be displaying signs of respiratory distress and her cough sounded like a viral croup, although she had looked for symptoms of other conditions as well.
Dr Sexton added: “Bacterial trachetis is a very rare condition that arises from these symptoms. I had not come across it prior to this case.”
Dr Sexton - who said she was not aware at the time of any separate NICE guidelines for croup - discussed the case with her senior, Dr Amar, and Evelyn was given a type of steroid. The fact that she had vomited an hour later was not considered of great significance because she would have already absorbed some of the dose and another would not be necessary.
* Haidee Vedy, head of medical negligence at Alsters Kelley LLP, who represented the family at the inquest said: “Evelyn’s death was an absolutely tragedy and should never have happened.
“Her family put their trust in the hands of the hospital and their local GP surgery and it would appear from the evidence presented at the inquest that they were badly let down.
“We will now be investigating further to find out what more could have been done to prevent Evelyn’s death.”
* In March this year Mr and Mrs Smith had a meeting with Glen Burley, chief executive of the South Warwickshire Foundation Trust along with senior staff.
At that time the couple were told the trust did not accept the findings of an independent report which highlighted missed opportunities to save their daughter’s life.
But at the inquest, Helen Lancaster, the director of nursing, who had commissioned the report, did accept its findings.
Mr and Mrs Smith said: “We feel bitterly disappointed in the trust for failing to acknowledge that changes in their practice needed to be made to reduce the risk of deaths in the future.
“This has added unnecessary distress to our family. This was compounded by a total absence of any aftercare once we had left the hospital after Evelyn died.”
* Dr John Omany, medical director for NHS England (Arden, Herefordshire and Worcestershire), who oversee GPs’ surgeries, accepted “opportunities were missed” to identify the seriousness of Evelyn’s condition.
Mr Omany added: “We have looked into the circumstances of this tragic case and our priority now is to ensure that GPs across our area are aware of the dangers of croup.
“We have also contacted all GP surgeries and all out-of-hours providers to highlight some of the difficulties in identifying seriously ill children, and encourage them to refer children for specialist care as a precaution as soon as they have any concerns.