'Neglect' contributed to death of Chloe Longster in Kettering General Hospital after catalogue of 'missed opportunities' that could have saved her life

The 13-year-old did suffer ‘neglect’ that contributed to her death, coroner Sophie Lomas said on Friday. Chloe went into KGH with a chest infection, then developed pneumonia and sepsis before dying less than 18 hours later in November 2022.

In a damning verdict following a five day inquest, Ms Lomas outlined a string of missed opportunities that could have changed the outcome for Chloe.

She said: “There could have been an altered outcome if her symptoms had been managed and identified earlier.”

Following the inquest’s conclusion, Chloe’s mum Louise said: “The pain of losing Chloe will never go away. She was the best of us. A lover of life that will no longer be able to experience it. We are pleased with the coroner’s findings of neglect. There was a catalogue of missed opportunities in care following Chloe’s admission into hospital.”

The verdict has alarming echoes of the case of Jorgie Stanton-Watts who also died after neglect on the same Skylark children’s ward in 2016. Some of the medical staff who treated her were the same.

Delivering her verdict, the coroner said several shortcomings in Chloe’s care amounted to neglect and that, on balance, she could have lived.

Outlining a string of missed opportunities that could have saved her, Ms Lomas said that medics should have implemented sepsis screening much earlier.

She said that a decision to transfer Chloe during a nursing handover meant staff were more focused on the handover than on providing care to Chloe. An escalation by a nurse to a doctor was then done during the doctor’s handover later that evening.

Ms Lomas outlined several missed opportunities to give Chloe earlier sepsis screening and to be given appropriate antibiotics which would have ‘quickly reduced the cascade of inflammatory response’. She said intubation should have been given earlier.

She said: “In my opinion there’s a clear causal link between the issues I have identified and Chloe’s death.”

Ms Lomas said she will now consider whether to contact regulatory bodies after finding some of the evidence given by medical staff ‘wholly unconvincing’.

“I remain concerned about some of the evidence,” she said. "I will consider whether referrals need to be made to the regulatory bodies in relation to individual practitioners.”

Outside the court, Mrs Longster added: “Both mine and Chloe’s grave concerns were either ignored or not taken seriously. Staff failed to identify that Chloe was in serious need of medical attention and no escalation was made that could have saved her life. Too many families have been through this heartache.

"It’s been excruciating this week to listen to their disagreement on fact. Justice for Chloe is having her true experience finally heard, acknowledged, and that no child will have to suffer again in the way she did. She should have been safe. She should have been in the safest place. Lessons must truly be learnt.”

She added that she wanted hospital staff to listen to parents that were worried about their children and children that are in pain.

"People don’t go to hospital for fun,” she said. “Nationally, sepsis needs to be taken more seriously.”

Following the verdict, Julie Hogg, the group chief nurse for the University Hospitals of Northamptonshire, said: "We offer our deepest condolences to Chloe's family for their loss. We are sorry that we failed to offer Chloe the care she deserved - we should have done more. In the two years since Chloe died our teams have worked hard to make significant improvements, including our management of patients with sepsis and those who are not getting better.

"We have also increased our staffing levels and improved the way we communicate with our patients and their families. We realise there is still more to do but we are committed to ensuring that every patient receives the best care.”

To find out more about sepsis, including the signs to look out for visit the Sepsis Trust website.